^JJa&fiSjftSTTY  OF  CALIFORNIA 


A  MANUAL  OF 

PRACTICAL  LABORATORY 
DIAGNOSIS 


BY 
LEWIS  WEBB  HILL,  M.D. 

Graduate  Assistant,  Children's  Hospital,  Boston 


WITH  ii  FIGURES  AND 
8  PLATES  —  4  IN  COLORS 


BOSTON 

W.  M.  LEONARD,  Publisher 
1916 

LIBRARY 


COPYRIGHT,  1916,  BY 
W.  M.  LEONARD 


PREFACE 

THE  author  realizes  that  it  may  seem  superfluous 
to  add  another  to  the  very  many  excellent  books  of 
laboratory  diagnosis  now  in  use.  His  purpose  is  this: 

It  has  seemed  to  him  for  a  long  time  that  all  the 
worth-while  laboratory  tests  that  a  practical  medical 
man  needs,  could  be  put  together  i»  a  small  and 
compact  volume.  This  should  be  gotten  up  in  such 
a  way  that  medical  students,  and  house-officers  doing 
their  hospital  ward  and  dispensary  work  can  carry  it 
in  their  pockets  for  ready  reference,  without  going 
to  the  trouble  of  hunting  through  all  the  various  al- 
ternative methods  of  performing  a  test  given  in  most 
of  the  larger  books.  Much  material  usually  in- 
corporated in  laboratory  manuals  has  been  left  out 
of  this  one,  and  purposely,  for  many  methods  and 
tests  which  are  of  scientific  value  and  of  theoretical 
interest,  are  not  practical  for  the  average  medical 
man  to  use.  It  has  been  the  author's  aim  to  include 
the  information  that  an  every  day  practitioner  wants, 
but  to  weed  out  carefully  all  tests  and  methods  which 
are  not  of  ordinary  clinical  application,  or  which  re- 
quire for  their  performance  complicated  apparatus 
and  trained  technicians.  Thus,  such  things  as  tissue 
staining  and  fixing,  the  Wassermann  reaction,  the 
gold  chloride  test,  etc.  —  have  been  purposely  omitted, 
as  these  are  not  ordinarily  performed  by  medical 
students,  house-officers,  and  general  practitioners,  for 
whom  this  book  is  intended. 


O  A  00-1 


IV 


It  is  a  pleasure  to  thank  Dr.  John  Lovett  Morse, 
Dr.  William  H.  Smith,  and  Dr.  Francis  W.  Peabody, 
for  their  helpful  suggestions  and  criticisms. 

For  the  plates  illustrating  the  sputum  we  are  in- 
debted to  Dr.  W.  H.  Smith,  and  to  Mr.  L.  H.  Brown, 
who  made  the  photographs. 

Most  of  the  plates  in  the  chapter  on  urine  were 
taken  from  Austin's  "  Clinical  Chemistry." 

BOSTON,  May  7,  1916. 


CONTENTS   AND    INDEX 


CHAPTER   I 

THE  URINE 

PAGE 

COLLECTION  OF  TWENTY-FOUR  HOUR  SPECIMEN i 

AMOUNT i 

APPEARANCE i 

COLOR i 

SPECIFIC  GRAVITY 3 

REACTION .  3 

ACIDITY 5 

ALBUMIN 5 

SUGAR 9-17 

OTHER  REDUCING  SUBSTANCES 17 

ACETONE  AND  DIACETIC  ACID 19 

AMMONIA 19 

BILE 21 

UROBILINOGEN. 23 

MELANIN 23 

BLOOD  PIGMENTS 23 

FORMALDEHYDE 23 

INDOXYL 25 

METALLIC  POISONS  —  LEAD,  MERCURY,  ARSENIC 25-31 

SEDIMENTS  —  ORGANIZED  AND  UNORGANIZED 3i~47 

KIDNEY  FUNCTION  TEST 47 

CHAPTER  II 
THE  BLOOD 

HEMOGLOBIN  ESTIMATION 51 

COLOR  INDEX 51 

COUNTING  THE  BLOOD  CELLS 53 

COUNTING  THE  BLOOD  PLATELETS 55 

v 


VI 

PAGE 

EXAMINATION  OF  THE  STAINED  SPECIMEN 57 

THE  BLOOD  CELLS,  NORMAL  AND  ABNORMAL  FORMS  . .     61-73 

THE  BLOOD  IN  INFANCY 73~75 

MALARIAL  PARASITES 75 

DOHLE'S  LEUCOCYTIC  INCLUSION  BODIES 79 

WIDAL  REACTION 81 

BLOOD  FRAGILITY  TEST 81 

HEMOLYSIS  TEST 85 

COAGULATION  TIME  . 87 

OBTAINING  BLOOD  FOR  CULTURES,  ETC 89 


CHAPTER  III 
FECES 

COLOR 93 

REACTION 93 

CONSISTENCY  AND  FORM 93 

MACROSCOPIC  EXAMINATION 95 

INTESTINAL  PARASITES 97 

CHEMICAL  EXAMINATION 99 

MICROSCOPIC  EXAMINATION 101 

THE  STOOLS  IN  INFANCY 113 


CHAPTER   IV 
GASTRIC   CONTENTS 

EXAMINATION  OF  THE  FASTING  CONTENTS: 

AMOUNT 123 

CONSISTENCY 123 

COLOR 123 

FOOD  . . : 123 

ODOR 125 

MICROSCOPIC  EXAMINATION 125 

CHEMICAL  EXAMINATION 127 

EXAMINATION  OF  THE  TEST-MEAL  CONTENTS: 

AMOUNT 129 

COLOR 129 

CHEMICAL  EXAMINATION 131 


Vll 

CHAPTER  V 

SPINAL  FLUIDS 

PACK 

PRESSURE 137 

APPEARANCE 137 

FIBRIN  CLOT 137 

AMOUNT 137 

CHEMICAL  EXAMINATION 139 

MICROSCOPIC  EXAMINATION 139 

CHARACTERISTICS  OF  THE  SPINAL  FLUID  IN  VARIOUS  DIS- 
EASES   145 


CHAPTER  VI 
PLEURAL  AND  PERITONEAL  FLUIDS 

TRANSUDATES 151 

EXUDATES 151 

EXAMINATION  OF  EXUDATES 153 

CHAPTER  VII 
SPUTUM 

SOURCE 155 

MACROSCOPIC  EXAMINATION ." 155 

MICROSCOPIC  EXAMINATION 159 

CHAPTER  VIII 
MISCELLANEOUS 

GRAM'S  STAIN  FOR  GONOCOCCUS 175 

SPIROCHAETA  PALLIDA 175 

SCHICK  TEST 175 

VON  PIRQUET  TEST 177 

GRAM-POSITIVE  AND  GRAM-NEGATIVE  ORGANISMS 177 

LEUCOCYTOSIS  IN  VARIOUS  DISEASES 179 


CHAPTER   I 
THE  URINE 

Collection  of  Twenty-four  Hour  Specimen.  Empty 
the  bladder  at  7  A.M.  and  throw  the  urine  away. 
Save  all  the  urine  passed  up  to  7  A.M.  the  next  day, 
passing  it  exactly  at  7,  and  adding  it  to  what  has 
already  been  saved. 

Amount.  The  normal  amount  of  urine  is  about 
1000  to  1500  c.c.  in  the  twenty-four  hours.  This,  of 
course,  is  subject  to  many  variations,  depending  upon 
the  fluid  intake,  the  amount  of  water  lost  with  the 
stools,  perspiration,  etc. 

Appearance.  Ordinarily  a  normal  urine  is  clear, 
but  a  cloudy  urine  is  not  necessarily  pathological. 
Turbidity  may  be  due  to : 

1.  Urates  or  phosphates  (usually  normal).     Urates 
are  particularly  likely  to  be  precipitated  in  a  con- 
centrated urine  in  a  cold  room.     If  due  to  phosphates, 
the  turbidity  clears  up  on  the  addition  of  a  little 
acetic  acid ;  if  due  to  urates,  it  clears  on  heating. 

2.  Pus,  or  a  combination  of  pus,  blood,  casts  and 
epithelial  cells. 

3.  Fat    (Lipuria).     A    rare    condition.     The    ad- 
dition of  ether  dissolves  the  fat  and  renders  the  urine 
clear. 

Color.  The  color  depends  largely  upon  the  amount 
or  urine  passed,  and  upon  the  percentage  of  total 
solids.  The  normal  color  may  vary  from  a  light 


yellow  to  a  rather  deep  orange.     The  main  abnormal 
colors  are: 

1.  Pink,  due   to   the  precipitation  of  amorphous 
urates  in  an  excessively  acid  urine. 

2.  Greenish  brown,  due  to  bile. 

3.  "  Smoky  "  or  mahogany  colored,  due  to  blood 
cells    and    casts   or    to    blood    pigment   and    bloody 
detritus. 

4.  Brown  or  black.     Urine  which  when  passed  is 
light  colored,  but  which  turns  dark  brown  or  black  on 
standing  (oxidation)  usually  contains  either  melanin 
(in   subjects  with   melanotic   sarcoma)    or   alkapton 
(a  metabolic  product). 

Specific  Gravity.  The  normal  specific  gravity 
varies  within  rather  wide  limits  —  1015  to  1025.  The 
gravity  depends,  as  does  the  amount,  on  several  fac- 
tors, such  as  fluid  intake,  loss  through  sweat,  etc. 
In  general  a  high  gravity  goes  with  a  small  amount, 
and  vice  versa.  The  principal  diseases  in  which  a  low 
specific  gravity  is  found  are  diabetes  insipidus  (1001 
to  1005)  and  chronic  interstitial  nephritis  (1008  to 
1015).  The  urine  in  diabetes  mellitus  is  of  high 
gravity  (1030  to  1050),  due  to  the  presence  of 
sugar. 

Reaction.  The  normal  urine  is  usually  acid,  the 
acid  reaction  being  due  to  acid  phosphates  in  solution. 
If  a  urine  is  alkaline  when  passed,  the  alkalinity  is 
most  likely  to  be  due  to  ammonia  formation  within 
the  bladder,  from  bacterial  activity  (cystitis)  or  to 
the  presence  of  large  amounts  of  carbonates  of  the 
alkalis,  which  are  derived  from  the  oxidation  of  the 
salts  of  the  organic  acids  of  vegetable  foods.  Nearly 
all  urine  becomes  alkaline  on  standing,  due  to  bac- 


terial  decomposition  with  ammonia  formation  from 
the  urea  in  the  urine. 

Quantitation  of  the  Acidity.  In  certain  cases  where 
there  is  increased  frequency  or  burning  micturition, 
it  is  of  value  to  know  whether  the  acidity  of  the 
urine  is  abnormally  high. 

FOLIN'S  METHOD.  To  25  c.c.  of  urine  add  a  drop 
or  two  of  a  I  per  cent  alcoholic  solution  of  phenol- 
phthalein,  and  15  or  20  grams  of  finely  powdered 
potassium  oxalate.  Shake  thoroughly,  and  titrate 
with  a  decinormal  sodium  hydroxide  solution.  The 
acidity  is  expressed  in  terms  of  grams  of  hydro- 
chloric acid.  Each  cubic  centimeter  of  decinormal 
sodic  hydrate  used  is  equivalent  to  .00365  gram  of 
hydrochloric  acid.  The  acidity  of  the  normal  twenty- 
four  hour  amount  of  urine  corresponds  to  between 
1.15  and  2.3  grams  of  hydrochloric  acid. 

ALBUMIN 

The  ordinary  protein  occurring  in  urine  is  serum 
albumin. 

Nitric  Acid  Test.  To  about  15  c.c.  of  filtered  urine 
in  a  small  urine  glass  add  about  5  c.c.  of  concentrated 
nitric  acid,  letting  it  run  gently  down  the  sides  of  the 
glass.  A  white,  flocculent  ring  at  the  zone  of  contact 
indicates  albumin.  This  test  reacts  to  all  urinary 
protein  except  peptone.  If  there  is  an  excess  of 
uric  acid  in  the  urine,  a  light  ring  similar  to  the 
albumin  ring  is  formed,  but  it  is  one  or  two  centi- 
meters above  the  zone  of  contact,  and  disappears  on 
gently  warming  or  diluting  the  urine.  Bile  pigment 
produces  a  greenish  ring  at  the  zone  of  contact. 
Indoxyl  produces  a  violet  ring.  A  rough  idea  of  the 


amount  of  albumin  present  may  be  formed  by  the 
thickness  of. the  ring,  and  may  be  reported  as  follows: 

1.  Slightest  possible  trace  (S.  P.  T.).  —  The  slight- 
est haze  which  can  be  detected,  against  a  dark  back- 
ground. 

2.  Very  slight  trace  (V.  S.  T.).  —  Slightly  more. 

3.  Slight  trace  (S.  T.).  —  A  fairly  thick  ring,  but 
one  which  can  be  hardly  seen  from  above,  when  look- 
ing down  through  the  glass. 

4.  Trace  (T).  —  Shows  a  thick,  heavy  ring,  which 
does  not  transmit  light  when  looked  down  upon  from 
above.     Not  flocculent  and  not  opaque.     About  .10 
per  cent  albumin. 

5.  Large    trace    (L.    T.).  —  Anything  more   than 
this. 

Heat  Test.  Fill  a  test  tube  one-third  full  of  urine 
and  gently  boil  the  top  part  of  it.  If  a  white  precipi- 
tate appears  in  the  heated  area  it  may  be  due  to 
albumin  or  to  phosphates.  Add  a  drop  or  two  of 
acetic  acid.  If  the  precipitate  is  due  to  phosphates  it 
disappears,  if  it  is  due  to  albumin  it  remains. 

If  a  urine  contains  protein,  it  is  nearly  always  serum 
albumin,  but  such  substances  as  serum  globulin, 
nucleo  albumin,  mucin  and  albumose  may  be  present 
and  give  the  nitric  acid  or  the  heat  test.  For  all 
practical  purposes  the  only  one  worth  considering  is 
albumose.  This  may  be  present  in  the  urine  of 
patients  with  multiple  myelomata  of  the  bone  mar- 
row. It  reacts  to  the  nitric  acid  and  heat  tests,  but 
may  be  distinguished  from  other  proteins  by  the 
fact  that  on  heating  gently  a  flocculent  precipitate 
falls  at  60°  C.,  which  dissolves  when  the  urine  is 
boiled,  and  reappears  when  it  is  cooled. 


The  quantity  of  albumin  present  may  be  approxi- 
mately estimated  by  the  method  of  Esbach  as  fol- 
lows: Fill  the  Esbach  tube  with  filtered  urine  to  the 
mark  U.  Then  add  Esbach's  reagent  (10  gm.  of 
picric  acid  and  20  gm.  of  citric  acid  in  a  liter  of  water) 
to  the  mark  R,  and  invert  the  tube  several  times. 
Let  it  stand  over  night,  and  read  off  from  the  gradu- 
ated tube  the  height  of  the  precipitate.  This  reading 
must  be  divided  by  10  to  obtain  the  percentage  of 
albumin. 

SUGAR 

The  only  important  sugar  found  in  the  urine  is 
dextrose  (grape  sugar).  Very  small  traces  of  it  occur 
normally,  but  these  small  amounts  are  not  recogniz- 
able by  any  of  the  tests  ordinarily  in  use.  Many 
tests  are  used  for  dextrose,  but  only  those  which  have 
been  found  most  serviceable  by  the  writer  in  practice 
will  be  given. 

In  any  reducing  test  for  sugar,  be  sure  that  no  chloro- 
form or  formaldehyde  has  been  added  to  the  urine  as  a 
preservative. 

1.  Fehling's  Test.     To  5  c.c.  of  hot  Fehling's  solu- 
tion in  a  test  tube  add,  a  few  drops  at  a  time,  5  c.c.  of 
urine,  boiling  after  each  addition.     If  sugar  is  present, 
a  yellow  or  a  red  precipitate  of  copper  oxide  is  formed. 

2.  Benedict's    Test.      To    5    c.c.    of    Benedict's 
reagent  add  8  drops  of  the  urine  to  be  examined. 
The  fluid  is  boiled  from  i   to  2  minutes,  and  then 
allowed  to  cool  of  itself.     If  dextrose  is  present  there 
results  a  red,  yellow  or  green  precipitate,  depending 
upon  the  amount  of  sugar  present.     If  no  sugar  is 
present  the  solution  may  remain  perfectly  clear  or 


II 

become  slightly  turbid,  due  to  precipitated  urates. 
This  is  a  more  delicate  test  than  Fehling's. 

Fehling's  solution  consists  of  two  reagents,  which  are  kept  in 
separate  bottles  and  are  mixed  in  equal  volumes  when  ready  for 
use. 

(a)  Copper  solution:  34.65  gm.  of  pure  copper  sulphate  in 
500  c.c.  water. 

(6)  Alkaline   solution:  173    gm.   crystallized    potassium    and 
sodium  tartrate  (Rochelle  Salt)  and  125  gm.  of  potassium  hydrox- 
ide dissolved  in  water  and  made  up  to  500  c.c. 
Benedict's  solution  has  the  following  composition: 

Copper  sulphate *  7  •  3  gm. 

Sodium  citrate J73-O  gni. 

Sodium  carbonate 100      gm. 

Distilled  water  to ..  1000  c.c. 


3.  Fermentation  Test.     If  Fehling's  test  is  positive 
and  there  is  any  doubt  as  to  whether  sugar  is  present 
or  not,  the  fermentation  test  is  useful  as  a  confirma- 
tory test.     About  100  c.c.  of  urine  is  put  into  a  small 
flask  and  a  quarter  of  a  yeast  cake  is  crumbled  up 
into  it,  and  the  whole  left  in  a  warm  place  for  from 
24  to  48  hours.     The  reduction  test  is  again  tried 
and  if  negative  this  time,  proves,,  that  a  fermentable 
sugar,    presumably    dextrose,    was    present    in    the 
original  sample  of  urine. 

4.  Ozazone  Test.     A  special  property  of  sugars  is 
the  formation  of  ozazones  when  treated  with  phenyl- 
hydrazine.      Each    sugar    has    its   own    ozazone,    of 
definite  melting  point  and  crystalline  configuration. 

Add  I  c.c.  of  phenylhydrazine  acetate  solution  (i 
part  glacial  acetic  acid,  I  part  water,  2  parts  phenyl- 
hydrazine, by  volume)  to  5  c.c.  of  urine  in  a  test  tube, 
and  heat  on  water  bath  for  half  an  hour.  Allow  the 
liquid  to  cool  slowly,  and  examine  the  crystals  micro- 
scopically (see  plate,  p.  31). 


13 
QUANTITATIVE   TESTS  FOR  DEXTROSE 

1.  Benedict's.     Measure  with  a  pipette  25  c.c.  of 
Benedict's  solution  into  a  porcelain  dish,  add  9  or 
10  grams   (approximately)   of  solid  sodic  carbonate, 
heat  to  boiling,  and  while  boiling,  run  in  the  urine 
from  a  burette  until  a  white  precipitate  forms.     Then 
add  the  urine  more  slowly,  drop  by  drop,  until  the 
last  trace  of  blue  disappears.     The  urine  should  be 
diluted  so  that  not  less  than  10  c.c.  will  be  required 
to  give  the  amount  of  sugar  which  the  25  c.c.  of 
reagent  is  capable  of  oxidizing.     A  dilution  of  I  to  10 
usually  answers. 

CALCULATION.  Five  divided  by  the  number  of 
cubic  centimeters  of  undiluted  urine  run  in,  equals  the 
per  cent  of  sugar. 

Benedict's  quantitative  solution  is  prepared  as  follows:  Dis- 
solve 9.0  gm.  of  copper  sulphate  in  100  c.c.  distilled  water. 
(The  copper  sulphate  must  be  weighed  very  accurately.)  Dis- 
solve 50  gm.  anhydrous  sodic  carbonate,  100  gm.  sodic  citrate, 
and  65  gm.  of  potassium  sulphocyanate  in  250  c.c.  of  distilled 
water. 

Pour  the  copper  solution  slowly  into  the  alkaline  citrate 
solution.  Then  pour  the  mixed  solutions  into  the  flask  without 
loss,  and  make  up  to  500  c.c.  25  c.c.  of  this  solution  is  reduced 
by  50  mgm.  of  dextrose,  or  67  mgm.  of  lactose. 

2.  Fermentation  Test.     Take  the  specific  gravity 
of  the  24°  urine,  put  100  c.c.  of  it  into  a  flask,  and 
add  to  it  a  quarter  of  a  crumbled  up  yeast  cake. 
Put  the  flask  in  a  warm  place  (at  about  body  tem- 
perature) and  allow  it  to  remain  over  night.     The 
next  morning  test  a  sample  of  the  fermented  urine 
for  sugar.     If  no  sugar  is  present  make  the  urine  up 
to  100  c.c.  (to  allow  for  the  water  that  has  evapo- 
rated) and  take  the  specific  gravity  again.     Multiply 
the  number  of  points  loss  in  specific  gravity  by  .23. 
This  gives  the  percentage  of  sugar  in  the  urine. 


15 
OTHER  SUGARS  IN  THE  URINE 

It  is  rare  to  find  any  sugar  but  dextrose  in  the 
urine,  but  levulose,  maltose,  pentose,  sucrose,  or 
lactose  may  occur. 

Levulose.  Reduces  Fehling's,  but  more  feebly 
than  does  dextrose. 

SELIWANOFF'S  REACTION.  To  loc.c.  of  urine  add 
a  small  amount  of  resorcin  and  2  c.c.  dilute  hydro- 
chloric acid,  mix  and  heat  in  a  test  tube.  If  levulose 
is  present  the  liquid  turns  red  and  precipitates  a  dark 
sediment,  which  is  soluble  in  alcohol,  with  the  forma- 
tion of  a  bright  red  color. 

Maltose.  Occurs  very  rarely  in  disease  of  the 
pancreas,  in  very  small  amounts.  Of  no  practical 
interest. 

Pentose.  Pentoses  reduce  Fehling's  solution  rather 
slowly.  They  do  not  ferment.  They  may  be  de- 
tected by  Bial's  orcin  test. 

BIAL'S  TEST.  Five  cubic  centimeters  of  Dial's 
reagent  (500  c.c.  of  30  per  cent  hydrochloric  acid, 
i  gm.  orcin,  and  25  drops  of  10  per  cent  ferric  chloride 
solution)  are  boiled  in  a  test  tube  and  the  urine  to  be 
tested  is  added  drop  by  drop.  A  green  color  indicates 
the  presence  of  a  pentose. 

Levulose,  maltose,  and  the  pentoses  occur  in  urine 
so  rarely  as  to  be  of  very  little  practical  importance. 

Lactose.  Lactose  may  occur  in  the  urine  of  preg- 
nant or  nursing  women.  It  reduces  Fehling's  solu- 
tion, but  does  not  ferment  with  pure  yeast,  and  does 
not  give  a  dextrosazone.  Lactose  may  be  detected 
by  Rubner's  test. 

RUBNER'S  TEST.  To  10  c.c.  of  urine  add  3  gm. 
of  lead  acetate ;  filter  off  the  precipitate  and  heat  the 


17 

filtrate  in  a  test  tube  until  a  yellowish  brown  color 
appears,  then  add  a  little  ammonia  and  continue 
heating.  If  lactose  is  present,  a  brick  red  color  ap- 
pears and  a  cherry  red  precipitate  settles  at  the  bot- 
tom of  the  test  tube,  while  the  liquid  above  becomes 
colorless. 

Sucrose.  May  rarely  occur  in  the  urine  after  eating 
large  amounts  of  saccharine  food.  It  does  not  re- 
duce Fehling's  or  Benedict's  solutions  and  is  of  no 
clinical  importance. 

OTHER  REDUCING  SUBSTANCES  IN  THE  URINE  WHICH 
MAY  BE   CONFUSED   WITH   DEXTROSE 

Drugs.  Certain  drugs,  such  as  chloral,  naphthol, 
antipyrin,  aspirin,  morphine,  camphor  and  menthol, 
cause  an  increase  in  the  conjugate  glycuronates 
(glycuronic  acid  conjugated  with  aromatic  bodies)  of 
the  urine.  These  substances  reduce  Fehling's  solu- 
tion, but  the  reduction  is  usually  of  a  dirty  yellow- 
green  color,  and  rarely  the  bright  yellow  or  red  of  a 
clean-cut  sugar  reaction.  Conjugated  glycuronic  acid 
may  be  distinguished  from  sugar  by  the  fact  that  it 
does  not  ferment  with  yeast.  Excessive  amounts  of 
creatinine  or  uric  acid  may  cause  a  partial  reduction 
of  copper  solution,  and  may  be  distinguished  from 
sugar  in  the  same  way  that  glycuronates  are. 

Alkapton,  a  product  of  abnormal  metabolism,  occurs 
in  the  urine  rarely  and  reduces  Fehling's  solution, 
but  does  not  ferment.  Urine  containing  alkapton 
turns  dark  brown  or  black  on  standing,  or  on  the 
addition  of  an  alkali. 

Protein.  If  a  large  amount  of  protein  is  present  in 
the  urine  it  may  cause  a  reduction  of  copper  solution. 


19 

If  this  is  suspected,  a  few  drops  of  acetic  acid  should 
be  added  to  the  urine,  and  it  should  be  boiled  a  few 
minutes  and  filtered  to  remove  the  precipitated 
protein. 

ACETONE  AND   DIACETIC  ACID 

Acetone.  To  5  c.c.  of  urine  add  a  crystal  of  sodium 
nitroprusside,  acidify  with  glacial  acetic  acid,  shake 
a  minute,  and  then  make  alkaline  with  ammonium 
hydrate.  A  purple  color  indicates  acetone. 

Diacetic  Acid.  To  5  c.c.  of  urine  add  an  excess  of 
a  10  per  cent  solution  of  ferric  chloride.  A  burgundy 
red  color  indicates  diacetic  acid.  After  the  taking 
of  certain  drugs,  especially  aspirin,  a  diacetic  acid 
reaction  may  appear  in  the  urine,  which  does  not  dis- 
appear on  heating.  The  red  color  if  due  to  diacetic 
acid,  disappears  on  heating. 

QUANTITATIVE   TEST  FOR  AMMONIA 

To  25  c.c.  of  urine  add  5  c.c.  of  a  saturated  solution 
of  potassium  oxalate  and  2  to  3  drops  of  a  I  per  cent 
alcoholic  solution  of  phenolphthalein.  Run  in  from  a 
burette  decinormal  sodic  hydrate,  to  a  faint  pink 
color.  Then  add  5  c.c.  of  formalin  (40  per  cent  com- 
mercial) and  again  titrate  to  the  same  color.  Each 
cubic  centimeter  of  the  decinormal  alkali  used  in  this 
last  titration  equals  I  c.c.  of  n/io  ammonia,  or 
.0017  gm.  of  ammonia.  Multiply  .0017  by  the  number 
of  cubic  centimeters  of  decinormal  alkali  used  in  the 
titration;  this  gives  the  number  of  grams  of  ammonia 
in  25  c.c.  of  urine.  The  potassium  oxalate  and  the 
formalin  must  both  be  neutral  to  phenolphthalein,  and 
the  urine  must  be  fresh. 


21 

The  value  of  quantitating  the  ammonia  is  that  it 
is  a  rough  index  to  the  amount  of  acidosis  in  diabetes. 
The  amount  of  ammonia  in  the  urine  varies  of  course 
with  the  amount  of  protein  ingested,  but  in  general 
an  ammonia  figure  of  I  to  2  grams  per  24  hours  may 
be  regarded  as  normal,  anything  over  this  indicates 
an  acidosis,  anything  over  4.0  gm.  a  severe  acidosis. 

BILE 

The  most  satisfactory  test  for  bile  for  general  use  is 
the  iodine  test.  To  15  c.c.  of  urine  in  a  test  tube  add 
5  c.c.  of  a  i  to  10  dilution  of  the  official  tincture  of 
iodine,  letting  it  run  gently  down  the  side  of  the 
tube.  A  green  ring  at  the  zone  of  contact  of  the  two 
liquids  indicates  bile. 

Gmelin's  Test.  Filtered  urine  is  allowed  to  slowly 
trickle  down  the  side  of  a  test  tube  containing  a  few 
cubic  centimeters  of  concentrated  nitric  acid.  If  bile 
is  present  several  colors  (green,  blue,  violet,  yellow) 
are  formed  at  the  line  of  junction  of  the  two  fluids. 

Hammarsten's  Test.  A  mixture  of  19  parts  of 
25  per  cent  hydrochloric  acid  and  I  part  of  25  per 
cent  nitric  acid  is  allowed  to  stand  at  room  tem- 
perature for  from  several  hours  to  a  day,  until  it  has 
turned  slightly  yellowish.  One  part  of  this  acid 
mixture  is  added  to  5  parts  of  95  per  cent  alcohol. 
A  few  drops  of  urine  are  added  to  a  few  cubic  cen- 
timeters of  this  acidulated  alcohol.  If  the  urine 
contains  bile  pigment,  a  characteristic  green  color 
appears  almost  immediately.  This  is  a  delicate  test. 

A  very  simple  and  fairly  satisfactory  test  is  to  dip 
a  piece  of  white  cotton  cloth  into  the  urine.  If  bile 
is  present  the  cloth  will  be  stained  yellow. 


23 
UROBILINOGEN 

Half  fill  a  small  test  tube  with  urine,  and  add  3  or 
4  drops  of  Ehrlich's  reagent  (2  per  cent  solution  of 
dimethyl-paramido-benzaldehyde  in  20  per  cent  hydro- 
chloric acid)  taking  care  that  the  reagent  remains  on 
top  of  the  urine.  A  cherry  red  color,  usually  appear- 
ing within  an  hour,  indicates  urobilinogen. 

MELANIN 

Urine  containing  melanin  is  dark  when  passed,  but 
turns  darker  on  the  addition  of  an  oxidizing  agent, 
such  as  ferric  chloride,  potassium  dichromate  or 
sulphuric  acid.  An  excess  of  the  oxidizing  agent  de- 
colorizes the  urine,  with  the  formation  of  a  yellow 
precipitate. 

Von  Jaksch-Pollak  Reaction  for  Melanin.  Add  a 
few  drops  of  ferric  chloride  solution  to  a  third  of  a 
test  tube  of  urine,  and  note  the  formation  of  a  gray 
color.  Upon  the  further  addition  of  the  chloride  a 
dark  precipitate  forms  consisting  of  phosphates  and 
adherent  melanin.  An  excess  of  ferric  chloride  causes 
the  precipitate  to  dissolve. 

BLOOD   PIGMENTS 
Guaiac  Test  (see  p.  127). 

FORMALDEHYDE 

Burnham's  Test.  To  5  c.c.  of  urine  in  a  test  tube 
add  5  drops  of  a  .5  per  cent  solution  of  phenylhydrazine 
hydrochloride,  a  crystal  of  sodium  nitroprusside,  and 
shake.  Now  add  a  few  drops  of  a  concentrated  solution 
of  sodic  hydrate.  If  formaldehyde  is  present  a  blue 
color  results,  slowly  passing  through  blue  to  brown, 


25 

red,  and  finally  yellow.  This  test  is  of  importance  in 
examining  the  urine  of  patients  who  are  being  treated 
for  pyelitis  with  urotropin.  If  the  test  for  formalin 
in  the  urine  is  negative  it  shows  that  the  urotropin  is 
not  being  broken  up  in  the  body,  and  is  consequently 
doing  the  patient  no  good. 

INDOXYL 

Obermayer's  Test.  Add  3  c.c.  of  a  20  per  cent 
solution  of  lead  subacetate  to  15  c.c.  of  urine,  and 
remove  the  precipitate  by  filtering.  (This  is  done  to 
get  rid  of  urobilin  and  any  other  coloring  matters 
that  may  be  present,  and  is  not  necessary  unless  the 
urine  is  very  highly  colored.)  Then  add  15  c.c.  of 
Obermayer's  reagent  (2  per  cent  solution  of  ferric 
chloride  in  strong  hydrochloric  acid)  and  shake  the 
mixture.  After  shaking,  3  c.c.  of  chloroform  is  added, 
and  the  mixture  is  again  shaken.  Indoxyl,  if  present, 
gives  a  blue  color  to  the  chloroform. 

METALLIC   POISONS 

The  most  common  cases  of  metallic  poisoning,  that 
one  sees  in  practice,  are  those  due  to  lead,  mercury  or 
arsenic.  Each  of  these  substances  appears  in  the 
urine,  and  their  quantitative  recognition  is  often  a 
matter  of  diagnostic  or  prognostic  importance. 

Lead.  Two  liters  of  urine  is  evaporated  to  a  tenth 
of  its  volume.  An  equal  volume  of  20  per  cent 
hydrochloric  acid  is  added,  and  3  gm.  of  potassium 
chlorate.  The  mixture  is  heated  on  the  water  bath 
to  60°  C.  As  soon  as  the  evolution  of  chlorine  has 
ceased  another  portion  of  3  gm.  of  potassium  chlorate 
is  added,  and  the  operation  repeated  until  the  fluid 


27 

no  longer  gives  off  the  fumes  of  chlorine  on  tfye  further 
addition  of  the  chlorate.  If  the  liquid  becomes  too 
concentrated,  more  water  is  added.  The  fluid  is  al- 
lowed to  cool  and  is  filtered  after  dilution  with  water. 
The  filtrate  is  examined  for  lead  with  hydrogen  sul- 
phide, sulphuric  acid,  and  potassium  bichromate, 
giving  precipitates,  if  lead  is  present,  of  black  lead 
sulphide,  white  lead  sulphate,  and  yellow  lead  chro- 
mate. 

Arsenic.  May  be  tested  for  by  saturating  the 
faintly  acid  urine  with  hydrogen  sulphide  gas,  allow- 
ing to  stand  from  12  to  24  hours,  filtering,  washing, 
treating  the  precipitate  with  bromine  water,  which 
will  dissolve  the  arsenic  sulphide.  The  solution  is 
placed  in  a  small  Erlenmayer  flask,  to  which  is  added 
zinc  and  sulphuric  acid,  and  the  stream  of  hydrogen 
is  conducted  into  an  acid  silver  nitrate  solution 
(AgNO3  i  to  2  gm.,  HNO3  2  gm.,  water  10  c.c.).  If 
AsH3  is  generated,  one  gets  a  blackish  brown  precipi- 
tate of  metallic  arsenic. 

Mercury  (method  of  Vogel  and  Lee).  "  150  c.c.  of 
urine  is  taken,  and  in  order  to  break  down  the  organic 
compound  in  which  the  mercury  is  likely  to  be  pres- 
ent, it  is  acidulated  with  5  c.c.  of  concentrated  hydro- 
chloric acid  and  evaporated  until  its  bulk  has  been 
reduced  to  25  or  30  c.c.  About  2  c.c.  of  hydrochloric 
acid  is  added  to  replace  the  loss  by  evaporation,  and 
enough  potassium  chlorate  to  oxidize  thoroughly  the 
organic  material  present.  This  usually  requires 
about  2  gm.  and  when  it  has  been  oxidized  the  fluid 
becomes  pale  yellow  or  colorless.  It  is  then  "diluted 
to  about  60  c.c.  and  is  boiled  vigorously  until  the 
chlorine  gas  previously  evolved  has  been  driven  off, 


Uric  Acid  Crystals. 


Acid  Ammonium  Urate. 


29 

which  is  shown  by  the  absence  of  chlorine  odor  from 
the  steam.  The  solution  usually  darkens  again  on 
cooling.  A  piece  of  copper  wire  about  4  cm.  in  length, 
bent  back  on  itself  twice,  and  cleaned  by  boiling  in  a 
test  tube  with  dilute  hydrochloric  acid,  is  dropped 
into  the  solution  and  allowed  to  remain  an  hour  or 
more.  If  considerable  amounts  of  mercury  are  present 
it  will  be  found  to  be  coated  with  a  silvery  film  of 
metallic  mercury;  but  this  is  not  sufficient  to  estab- 
lish the  identity  of  the  metal,  and  if  it  exists  only  in 
traces  the  changes  in  the  appearance  of  the  urine  may 
be  inconclusive.  The  wire  is  accordingly  removed 
from  the  dish  with  a  glass  rod,  is  washed  with  a  little 
water,  and  is  gently  dried  by  rolling  it  on  a  piece  of 
filter  paper,  pains  being  taken  to  avoid  unnecessary 
handling. 

"  It  is  then  put  into  the  bottom  of  a  glass  tube  from 
3  to  5  mm.  in  diameter  and  15  cm.  long,  which  is 
sealed  at  one  end  and  is  followed  by  a  cylindrical  plug 
of  gold  leaf  which  is  pushed  into  the  tube  until  it  is 
within  2  cm.  of  the  wire.  (Such  ^pellets  of  gold  leaf 
may  be  obtained  from  any  dentist.)  Holding  the 
tube  horizontally,  the  end  containing  the  wire  is 
gradually  heated,  the  part  of  the  tube  containing  the 
gold  leaf  not  to  be  heated.  The  latter  must  be  ex- 
amined frequently  for  any  change  of  color,  especially 
the  end  of  the  cylinder  toward  the  wire.  If  mercury 
is  present  it  will  manifest  itself  by  the  appearance 
of  a  silver  patch  of  amalgam  in  this  situation. 

"  If  the  amount  of  the  metal  is  very  small  there  will 
be  simply  a  pale  discoloration  of  the  gold,  but  if  the 
amount  is  larger,  the  deposit  on  the  gold  will  be  very 
easy  to  recognize.  If  further  confirmation  of  the 


Glucosazone  Crystals. 


Amorphous  Urates. 


identity  of  the  mercury  is  required,  the  gold-foil  may 
be  suspended  in  a  tube  containing  a  few  crystals  of 
iodine,  which  are  then  very  gently  warmed.  The 
mercury  thus  becomes  converted  into  red  mercuric 
iodide,  or  if  the  amount  is  considerable  the  metal  may 
be  distilled  by  heating  the  gold  foil  in  the  tube  and 
looking  with  the  lens  for  a  deposit  of  very  minute 
droplets  of  metallic  mercury  in  the  cooler  parts  of  the 
tube." 

SEDIMENTS 

i.    UNORGANIZED  SEDIMENTS 

Uric  Acid.  Uric  acid  occurs  in  acid  urines  in  a 
variety  of  crystalline  forms.  Some  of  the  more  com- 
mon forms  are:  "  Dumb-bells,"  "  whetstones,"  hexag- 
onal plates,  rhombic  prisms  or  wedges.  The  crystals 
are  usually  yellowish  in  color.  Uric  acid  crystals  are 
soluble  in  alkalis,  and  hence  do  not  occur  as  a  sedi- 
ment in  alkaline  urine.  They  have  little  clinical 
significance,  unless  associated  with  blood  or  other 
evidence  of  renal  or  ureteral  irritation,  when  the 
possibility  of  calculus  formation  should  be  borne  in 
mind. 

Urates.  Urates  may  occur  singly  or  as  a  mixture  of 
ammonium,  calcium,  magnesium,  potassium,  and 
sodium  urates.  Ammonium  urates  may  occur  in 
acid,  neutral  or  alkaline  urine,  but  all  the  other  urates 
occur  as  sediment  only  in  acid  urine.  Calcium, 
magnesium,  and  potassium  urates  are  amorphous, 
ammonium  urate  is  crystalline,  and  sodium  urate  may 
be  either  amorphous  or  crystalline.  Ammonium 
urate  ordinarily  occurs  in  the  form  of  the  so-called 
"  thorn  apple,"  crystals,  while  sodium  urate,  when 


FIG.  I.     Calcium  Phosphate 


FIG.  2.     Ammonio-magnesium  Phosphate 


33 

crystalline,  occurs  as  fan-shaped  clusters  or  prismatic 
needles.  The  urates  are  all  soluble  in  hydrochloric 
or  acetic  acid.  The  most  common  urate  sediments  seen 
are  the  "  thorn  apple  "  crystals  of  ammonium  urate, 
and  the  so-called  "  brick  dust "  pinkish  precipitate  of 
amorphous  urates.  Urate  sediments  have  little  clinical 
significance,  and  are  especially  seen  in  rather  concen- 
trated, highly  acid  urines. 

Phosphates.  Phosphates  may  occur  as  calcium  or 
magnesium  phosphate  or  as  ammonium  magnesium 
phosphate  (triple  phosphate).  Calcium  phosphate 
may  occur  in  crystalline  or  amorphous  form.  It 
appears  in  the  sediment  of  slightly  acid,  neutral  or 
faintly  alkaline  urine.  The  crystalline  form  is  seen  in 
long  glistening  prismatic  needles,  which  may  be 
arranged  singly  or  in  bundles  or  rosettes.  Amor- 
phous phosphates  (calcium  and  magnesium)  are  usually 
seen  in  alkaline  urines,  but  may  be  present  if  the  re- 
action is  slightly  acid  or  neutral.  Microscopically 
they  are  seen  as  granular,  colorless  masses,  and  are 
dissolved  by  acetic  acid  but  not  by  heat.  Magnesium 
phosphate  crystals  are  not  common.  They  are  found 
rarely  in  alkaline  urines  in  the  form  of  rhomboid 
plates,  which  are  soluble  in  acetic  acid.  Ammonium 
magnesium  phosphate  (triple  phosphate)  occurs  usually 
in  alkaline  urines,  and  is  seen  in  the  form  of 
rhomboid  prisms  of  characteristic  appearance,  the 
so-called  "  coffin  lid  "  form.  Occasionally  they  may 
closely  resemble  the  large  envelope  forms  of  calcium 
oxalate,  but  may  be  distinguished  from  them  by 
their  ready  solubility  in  acetic  acid.  The  most  com- 
mon phosphates  seen  are  the  amorphous  phosphates,  and 
the  ammonium  magnesium  phosphate.  These  two  forms 


FIG.  3.     Calcium  Oxalate  Crystals 


FIG.  4.     Leucin  and  Tyrosin 
I,   Leucin  and  2,  Tyrosin  Crystals 


35 

commonly  occur  in  urines  that  have  been  standing  and 
have  become  alkaline,  and  are  of  little  clinical  significance. 
When  occurring  in  freshly  passed  urine,  they  indicate 
ammoniacal  fermentation,  due  possibly  to  cystitis  or 
to  retention  of  residual  urine. 

Calcium  Oxalate.  Calcium  oxalate  crystals  occur 
in  the  urine  in  two  forms,  the  dumb-bell  type  and  the 
octahedral  type.  They  are  found  most  frequently  in 
acid  urines,  but  may  occur  in  neutral  or  alkaline 
urines  as  well.  They  are  insoluble  in  acetic  acid,  but 
soluble  in  hydrochloric.  Oxalates  are  derived  from 
various  vegetable  foods,  particularly  spinach  and 
rhubarb,  and  if  present  in  the  urine  in  large  numbers 
are  of  some  clinical  importance,  indicating  the  possible 
formation  of  a  calculus. 

Calcium  Carbonate.  Calcium  carbonate  crystals 
are  not  common  in  human  urine.  They  occur  usually 
in  alkaline  urine,  but  may  occur  in  neutral  or  very 
slightly  acid  urines.  The  crystals  are  in  the  form  of 
granules,  spherules  or  dumb-bells.  They  may  be 
differentiated  from  calcium  oxalate  by  the  fact  that 
they  dissolve  in  acetic  acid  with  the  evolution  of 
carbon  dioxide  gas.  They  are  of  no  practical  im- 
portance. 

Calcium  Sulphate.  Calcium  sulphate  crystals 
occur  rarely  in  the  urine.  They  are  found  usually  in 
very  strongly  acid  urines,  are  of  long  needle-like 
shape,  and  are  insoluble  in  acetic  acid. 

Leucin  and  Tyrosin.  Leucin  and  tyrosin  occur 
rarely  in  the  urine.  When  they  do  occur  it  is  usually 
in  the  urine  of  parents  with  acute  yellow  atrophy  or 
cirrhosis  of  the  liver,  in  acute  phosphorus  poisoning, 
or  in  leukemia.  They  may  be  in  solution,  or  as  a 


37 

sediment.  Leucin,  when  crystalline,  occurs  in  spher- 
ical masses,  which  show  characteristic  radial  and 
concentric  striations,  and  are  highly  refractive. 
Tyrosin  occurs  in  the  characteristic  "  sheaf "  for- 
mation. 

TESTS  FOR  LEUCIN  AND  TYROSIN.  As  leucin  and 
tyrosin  sometimes  occur  in  solution  in  the  urine,  if 
they  are  suspected,  the  urine  should  be  evaporated  to 
a  small  bulk  and  the  following  tests  applied. 

Leucin.  Scherer's  Test.  To  the  residue  of  the 
evaporated  urine  add  alcohol,  which  may  then  be 
examined  for  the  characteristic  crystals.  In  order 
to  identify  the  crystals  chemically  as  leucin  it  is  neces- 
sary to  evaporate  with  concentrated  nitric  acid  on  a 
platinum  crucible  cover  some  of  the  solid  residue 
obtained  after  adding  alcohol  to  the  evaporated 
urine.  With  pure  leucin  the  residue  remains  color- 
less, but  usually  a  yellowish  residue  remains.  This 
is  heated  with  a  few  drops  of  sodium  hydrate  solu- 
tion, when  a  yellowish  or  brownish  color  appears.  If 
it  is  heated  further,  the  leucin.  collects  into  an  oily 
drop  which  rolls  around  on  the  crucible  cover. 

Tyrosin.  Evaporate  the  urine  to  a  small  bulk,  re- 
move the  fluid  and  dissolve  the  residue  in  water. 
Morner's  test  is  then  used.  To  this  aqueous  solution 
add  i  c.c.  of  a  reagent  composed  of  I  c.c.  of  formalin, 
55  c.c.  of  concentrated  sulphuric  acid  and  45  c.c.  water. 
When  the  mixture  is  heated  to  boiling  a  green  color 
appears  if  tyrosin  is  present. 

Hematoidin.  Hematoidin  crystals  may  occur  in 
the  urine  of  persons  with  various  liver  diseases. 
They  may  be  seen  as  tufts  of  small  needles  or  as 
small  yellowish  red  plates. 


39 

Fat.  Free  fat  is  very  rarely  seen  in  the  urine. 
(Lipuria,  chyluria.)  Before  it  is  decided  that  the  fat 
droplets  seen  have  actually  come  from  the  urinary 
tract,  all  sources  of  contamination  must  be  excluded, 
such  as  grease  in  the  vessel  in  which  the  urine  is 
obtained,  oil  on  the  fingers  when  manipulating  the 
cover  glass,  dirt  on  the  slide,  etc.  Lipuria. is  so  rare 
that  free  fat  droplets  seen  in  the  urine  practically 
always  come  from  one  of  these  contaminations.  Fat 
droplets  may  occur  quite  commonly  on  fatty  casts, 
however.  (See  below.) 

Starch  Granules.  Starch  granules  may  occur  in 
the  urine  of  babies  who  have  had  dusting  powder  ap- 
plied to  their  buttocks.  They  may  be  easily  recog- 
nized by  the  fact  that  they  turn  blue  with  iodine. 


2.    ORGANIZED    SEDIMENTS 

i.  Epithelial  Cells.  As  the  genito-urinary  tract  is 
lined  with  epithelium  and  as  this  is  continually 
desquamating,  a  few  epithelial  cells  of  various  sorts 
are  normally  found  in  the  urine.  If  these  cells  are 
found  in  abnormally  large  numbers  their  presence 
indicates  irritation  or  inflammation  of  the  part  of  the 
genito-urinary  tract  from  which  they  come* 
Epithelial  cells  may  roughly  be  divided  into  four 
classes. 

(a)  Small  round  cells,  about  the  same  size  as  pus 
cells.  They  may  be  differentiated  from  pus  cells  by 
the  fact  that  they  are  mononuclear.  They  may 
come  from  the  renal  tubules,  or  from  the  urethra  or 
from  the  pelvis  of  the  kidney.  If  they  adhere  to- 
gether in  clumps  thay  are  probably  from  the  renal 


pelvis  or  the  urethra;    if  they  are  on  casts  they  are 
from  the  renal  tubules. 

(b)  Large  round  cells  two  or  three  times  the  size 
of  the  small  ones  may  come  from  the  neck  of  the 
bladder  or  the  membranous  or  prostatic  urethra. 


i- 


3- 


FIG.  5.     i.  Large  round  cells.    2.  Caudate  cells.     3. 
round  cells.     4.  Squamous  cells. 

(c)  Large  squamous   cells   usually  come   from  the 
the  bladder  or  from  the  prepuce,  or  vagina  or  vulva. 

(d)  Caudate  cells  come  from  the  pelvis  of  the  kidney 
or  from  the  neck  of  the  bladder  or  ureter. 

2.   Leucocytes  (Pus  Cells).     A  few  leucocytes  may 
occur  normally,  in  the  urine,  especially  in  the  urine 


FIG.  6.     Epithelial  Casts 


FIG.  7.     Hyaline  Casts 


43 

of  females,  who  are  likely  to  have  leukorrhea.  For 
this  reason  if  there  is  any  question  of  pus  in  a  female's 
urine,  it  is  desirable  to  have  a  catheter  specimen  to 
exclude  pus  from  the  uterus,  cervix,  vagina  or  ex- 
ternal genitalia.  Be  especially  careful  in  young 
female  children  and  babies,  not  to  make  a  diagnosis 
of  pyelitis  because  there  are  a  few  pus  cells  in  the 
urine;  these  are  usually  normal.  Pus  cells  may  be 
recognized  by  their  poly  nuclear  nuclei,  and  these 
may  be  made  to  show  more  prominently  if  a  drop  of 
acetic  acid  is  run  under  the  cover  glass. 

3.  Red  Blood  Cells.     The  occurrence  of  red  blood 
cells  in  the  urine  is  always  abnormal  (exclude  trauma 
from    the   catheter   and   menstruation).     Be   careful 
not   to   confuse  red   cells  with  yeast  cells,   a  great 
variety  of  which   may  appear  in   stale  urine.     The 
yeasts  are  smaller,  are  likely  to  be  more  irregular  or 
oval  in  shape   and    do    not  show  the   characteristic 
refractive  outside  ring  peculiar  to  red  cells,  or  the  flat 
biscuit  shape  seen  when  they  are  looked  at  sideways. 

4.  Animal   Parasites   or   their    Ova.     If   there   is 
echinococcus  disease  of  the  kidney,   small  cysts  or 
booklets   from   cysts   may   be   passed   in    the  urine. 
Other  parasites  which  occur  very  rarely  in  the  urine 
are   the   round   worms  Ascaris  and   Filaria,  and  the 
embryo  of  Bilharzia  (Egypt). 

5.  Yeasts  and  Bacteria.     Normal  urine  taken  by 
catheter  from  the  bladder  is  sterile,  but  on  standing 
many  yeasts  and  bacteria  develop,  so  that  if  it  is  de- 
sired to  determine  the  presence  or  absence  of  a  bac- 
teriuria  it  is  necessary  to  obtain  a  catheter  specimen. 
The  most  important  bacteria  to  be  looked  for  in  urine 
are   the   colon,   typhoid,   and   tubercle   bacilli.     The 


FIG.  8.     Fatty  Casts 


FIG.  9.     Cylindroids 


45 

colon  and  typhoid  bacilli  may  be  determined  by 
culture,  and  roughly,  by  their  characteristic  morphol- 
ogy in  the  fresh  urine  specimen  examined  under  the 
microscope.  To  recognize  tubercle  bacilli  a  smear  of 
the  urinary  sediment  is  made  and  stained  (see  p.  159, 
and  be  sure  to  exclude  smegma  bacilli)  or  a  few  cubic 
centimeters  of  the  urine  are  injected  into  a  guinea 
pig.  The  pig  is  killed  in  six  weeks,  and  the  presence 
or  absence  of  tuberculosis  determined  at  autopsy. 
6.  Casts.  Casts  have  two  particular  characteristics : 

1.  One  end  is  rounded,  sometimes  both  ends. 

2.  Their  sides  are  parallel.     (Cabot.) 

They  may  be  divided  into  six  classes: 

(a)  Epithelial  casts  are  covered  with  small  round 
cells  from  the  kidney  tubules. 

(b)  Bloody  casts  have  red  blood  cells  adherent 
to  them. 

(c)  Granular  casts  are  the  most  common  ones 
seen;    they  are  covered  with  coarse  yellow  granules, 
probably   the   degenerated   remains   of  epithelial   or 
blood  cells. 

(d)  Waxy  casts  are  clear,  yellowish  or  bluish, 
broader  than   the  other  varieties,  and   are    usually 
seen  with  broken  off  square  ends,  as  if  they  were 
brittle. 

(e)  Hyaline  casts  are  pale  and  watery  looking, 
and  cannot  be  seen  well  through  the  microscope  unless 
the  light  is  shut  down. 

(/)  Fatty  casts  have  small  globules  of  fat  ad- 
herent to  them,  which  may  be  recognized  by  staining 
with  a  drop  of  Sudan  III  solution.  Their  presence 
means  chronic  parenchymatous  nephritis. 


Waxy  Casts. 


Granular  Casts. 


47 

Cylindroids  consist  probably  of  mucus  or  mucus- 
like  material.  They  are  longer  than  casts,  more 
irregular  in  outline,  and  have  sharp,  tapering  ends. 
They  are  of  no  particular  significance. 

SULPHONEPHENOLPHTHALEIN   TEST   OF   KIDNEY 
FUNCTION.     (Rowntree  and  Geraghty) 

One  cubic  centimeter  of  the  'phthalein  solution  * 
is  injected  into  the  muscles  of  the  back,  and  all  the 
urine  passed  in  the  next  two  hours  is  saved.  A  few 
cubic  centimeters  of  strong  sodic  hydrate  solution  is 
added  to  make  the  urine  strongly  alkaline,  the  alkaline 
urine  is  made  up  to  1000  c.c.  by  the  addition  of  tap 
water,  and  the  red  color  is  compared  with  a  standard, 
and  the  result  expressed  in  terms  of  per  cent  of  this 
standard.  • 

The  large  Dubosq  colorimeter  may  be  used,  or  a 
small  one  made  by  Hynson,  Westcott  Co.,  or  a  series 
of  standard  test  tubes  made  by  oneself. 

Directions  for  Making  Standard  Tubes.  Add  a  few 
cubic  centimeters  of  strong  sodic  hydrate  solution  to 
I  c.c.  of  'phthalein  solution  in  a  1000  c.c..  graduate, 
and  make  up  to  1000  c.c.  with  tap  water.  This  is 
the  100  per  cent  solution.  The  other  dilutions  may  be 
made  up  from  this  as  follows:  To  make  an  80  per  cent 
solution  take  80  c.c.  of  the  first  (100  per  cent)  solution 
and  add  20  c.c.  of  water;  for  a  60  per  cent  solution, 
60  c.c.  of  the  first  solution,  and  40  c.c.  of  water,  and 

*  .60  gm.  of  sulphonephenolphthalein  and  ^.84  c.c.  of  double 
normal  sodium  hydrate  solution  are  diluted  to  100  c.c.  with  .75 
per  cent  saline  solution,  when  .15  c.c.  more  of  the  double  normal 
sodic  hydrate  solution  is  added.  The  resulting  product  is  filtered, 
and  contains  6  mgm.  of  sulphonephenolphthalein  to  the  cubic 
centimeter.  This  solution  may  be  obtained  from  Hynson,  West- 
cott Co.,  Baltimore,  put  up  in  very  convenient  I  c.c.  ampoules. 


49 

so  on  for  all  the  percentages  down  to  10.  The  stand- 
ard solutions  are  best  kept  tightly  stoppered  in  large 
test  tubes  in  a  rack  in  a  dark  place,  as  they  deteriorate 
in  the  light. 

The  normal  function  in  adults  varies  between  some- 
what wide  limits:  50  to  75  per  cent.  In  children  it 
is  somewhat  higher,  from  70  to  90  per  cent. 


CHAPTER    II 
THE    BLOOD 

Hemoglobin  Estimation  (Tallqvist).  A  drop  of 
blood  is  secured  from  the  ear,  and  is  allowed  to  fall 
upon  a  piece  of  dry  white  absorbent  paper.  The 
blood  is  allowed  to  stand  a  minute  until  it  has  lost  its 
glistening  appearance,  the  paper  is  then  folded  over 
so  there  will  be  a  background  of  white  paper  against 
and  underneath  the  blood  drop,  and  the  color  of  the 
blood  is  compared  with  the  graded  Tallqvist  scale. 
The  hemoglobin  is  read  off  directly  in  per  cent.  Do 
not  hold  your  finger  as  a  background  against  the 
blood  on  the  paper  when  you  are  comparing  it  with 
the  scale;  this  makes  it  look  too  dark.  The  normal 
hemoglobin  percentage  is  80  to  100.  This  is  the 
simplest  of  the  hemoglobin  tests,  but  is  not  accurate. 

Sahli  Method.  Draw  the  blood  up  to  the  mark  in 
the  small  pipette.  Then  blow  it  out  into  the  gradu- 
ated tube,  and  add  •£$  hydrochloric  acid  up  to  the 
mark  10.  Mix  well  by  a  rotary  motion.  Then  add 
water  drop  by  drop  until  the  color  in  the  graduated 
tube  matches  the  color  in  the  standard  tube.  The 
height  of  the  column  of  liquid  in  the  graduated  tube 
indicates  the  percentage  of  hemoglobin. 

Color  Index.  The  color  index  is  the  percentage  of 
hemoglobin  divided  by  the  percentage  of  the  normal 
number  of  red  corpuscles.  The  normal  color  index 
is  of  course,  I. 

51 


Neubauer  Ruling.  Breuer  Ruling. 

FIG.  10.     Diagrams  showing  various  hemacytometer  rulings. 


53 

Counting  the  Blood  Cells.  A  number  of  variously 
ruled  counting  apparatuses  are  in  use,  but  the  Thoma- 
Zeiss  is  the  one  most  commonly  used,  and  is  the  one 
referred  to  here.  The  counting  chamber  is  .1  mm. 
deep.  The  big  ruled  square  is  I  sq.  mm.  in  area. 
It  contains  therefore  ^  sq.  mm.  Each  of  the  small- 
est squares  is  -%^-Q  sq.  mm.  in  area,  and  contains 

Wfr <T  cu-  mm' 

Count  of  the  Red  Cells.     The  blood  is  drawn  up  in 

the  red  counting  pipette  to  the  mark  .5,  and  then 
the  diluting  solution*  is  added  to  the  mark  101, 
giving  a  dilution  of  I  to  200.  Be  sure  and  shake  well, 
best  with  a  rotary  motion,  to  mix  thoroughly  the 
blood  and  diluting  solution.  After  well  mixing,  2  or 
3  drops  are  allowed  to  run  out  of  the  pipette  and  are 
discarded,  after  which  a  small  drop  is  run  on  to  the 
counting  stage  and  covered  with  the  cover  glass, 
pressing  the  glass  down  with  the  finger,  so  that  the 
drop  is  very  evenly  distributed.  The  drop  should  be 
large  enough  to  cover  the  stage  when  the  glass  is 
pressed  down.  Now  count  the  number  of  cells  (the 
white  cells  have  been  dissolved  away  by  the  diluting 
fluid)  in  four  corner  blocks  of  25  squares  each,  add 
the  four  counts  together  and  multiply  the  result  by 
8000.  This  gives  the  number  of  red  cells  per  cubic 
millimeter  of  blood.  It  is  best  to  count  two  drops 
and  take  the  average.  The  normal  red  count  is 
about  5,000,000. 

Count  of  the  White  Cells.  Draw  up  the  blood  to 
the  mark  .5  on  the  white  counting  pipette,  and  fol- 
low with  diluting  fluid  (.5  acetic  acid)  to  the  mark  n. 

*  Gower's  Solution  =  sodium  sulphate  7  gm.,  acetic  acid  20 
gm.,  water  120  cc. 


55 

This  gives  a  dilution  of  I  to  20.  Put  the  drop  of 
diluted  blood  on  the  slide  as  in  the  red  count,  and 
count  all  the  cells  in  the  large  ruled  square.  Multiply 
this  count  by  200,  which  gives  the  number  of  white 
cells  per  I  cu.  mm.  of  blood.  If  especial  accuracy  is 
desired,  it  is  well  to  count  2  separate  drops,  add  the 
two  counts  together,  and  multiply  by  100. 

The  normal  white  count  varies  from  7000  to 
10,000. 

COUNTING   THE   BLOOD   PLATELETS 

1.  Draw  the  blood  up  in  the  red  counter  just  as  in 
doing  a  red  count,  to  the  mark  .5. 

2.  Draw  up  diluting  stain  *  to'the  mark  101. 

3.  Place  a  drop  of  blood  on   the  counting  stage 
just  the  same  as  for  a  red  count,  put  on  the  cover  glass, 
and  let  stand  for  a  few  moments  to  allow  the  platelets 
to  settle. 

4.  Count  all  the  platelets  in   100  of  the  smallest 
squares,  25  at  each  corner  of  the  large  square. 

5.  Multiply  this  count  by  8qob.     This  gives  the 
number  of  platelets  in  i  cu.  mm.  of  blood. 

The  normal  platelet  count  by  this  method  varies 
from  226,000  to  367,000  (Wright). 

The  platelets  appear  as  sharply  outlined,  oval  or 

*  The  diluting  fluid  for  counting  the  platelets  consists  of  3 
parts  of  a  i  to  1400  aqueous  solution  of  potassium  cyanide,  and 
2  parts  of  a  i  to  300  aqueous  solution  of  brilliant  cresyl  blue. 
These  two  solutions  are  kept  in  an  ice  chest  in  separate  bottles, 
and  are  mixed  and  filtered  just  before  being  used.  The  cresyl 
blue  solution  is  permanent,  but  the  potassium  cyanide  should  be 
made  up  fresh  at  least  every  10  days. 


57 

round  lilac-colored  bodies ;  the  red  cells  are  decolorized 
and  appear  as  shadows. 

A  common  mistake  made  is  to  count  the  yeasts  in 
the  staining  fluid  instead  of  the  platelets.  These  are 
much  darker  and  larger  than  the  platelets  are,  and 
if  the  stain  is  kept  on  ice  there  will  be  no  yeasts. 
The  platelets  can  be  seen  better  if  the  specially  thin 
cover  glass  of  Zeiss,  with  a  central  excavation,  is 
used. 

EXAMINATION   OF  THE   STAINED    SPECIMEN 

Technique  of  Making  Smear.  The  best  method  of 
making  a  blood  smear  is  upon  small  square  cover 
glasses.  It  is  absolutely  essential  that  these  be  clean, 
and  free  from  grease.  The  best  method  of  cleaning' 
them  is  to  soak  them  for  a  few  moments  in  concen- 
trated nitric  acid,  and  then  to  successively  wash 
with  water,  alcohol,  and  ether,  drying  on  a  soft 
cloth. 

The  ear  is  punctured  and  the  cover  glass  touched  to 
the  resulting  drop  of  blood.  Then  the  second  cover 
glass  is  dropped  over  the  first,  the  drop  of  blood  is 
allowed  to  spread,  and  the  cover  glasses  are  quickly 
drawn  apart,  with  a  sideways,  but  with  no  up  or 
down  motion.  The  whole  success  of  a  blood  smear 
depends  on  securing  a  uniform  and  very  thin  film  of 
blood.  The  important  points  to  observe  to  attain 
this  are: 

1.  Do  not  have  too  big  a  drop  of  blood. 

2.  Let  the  drop  of  blood  spread  thoroughly,  but 
do  not  wait  long  enough  before  pulling  the  glasses 
apart,  for  coagulation  to  have  started. 

3.  In  pulling  the  cover  glasses  apart,  use  only  a 


59 

sliding  motion;  do  not  lift  the  top  cover  glass  from 
the  bottom  one.  No  fixing,  other  than  drying  for  a 
moment,  is  necessary.  The  smear  is  now  ready  to 
stain.  The  most  satisfactory  stain  for  general  use 
is  Wright's  modification  of  Leishmann's  stain.  The 
technique  of  applying  it  is  as  follows  (Wright) : 

1.  Cover  the  film  with  a  known  quantity  of  the 
staining  fluid,  by  means  of  a  medicine  dropper. 

2.  After  one  minute  add  to  the  staining  fluid  the 
same  quantity  of  distilled  water,  and  allow  it  to  re- 
main two  or  three  minutes,  according  to  the  density 
of  the  stain  desired.     A  longer  period  of  staining  may 
produce  a  precipitate.     Eosinophilic  granules  are  best 
brought  out  by  a  shorter  period  of  staining.     The 
quantity  of  diluted   fluid  on  the  preparation  should 
not  be  so  large  that  some  of  it  runs  off. 

3.  Wash    the    preparation    in    water    for    thirty 
seconds,  or  until  the  thinner  portions  of  it  become 
yellow  or  pink  in  color. 

4.  Dry  and  mount  in  balsam. 


THE  BLOOD    CELLS 

The  Red  Blood  Cells.  The  normal  red  blood  cells- 
appear  as  nearly  round  bodies  of  a  fairly  uniform  size 
and  color,  of  about  6  to  9  microns  in  diameter. 

The  Blood  Platelets.  These  are  small  bodies,  stain- 
ing purple,  about  one-half  to  one-third  as  large  as  a 
red  cell,  which  usually  occur  in  groups.  They  have 
been  variously  considered  to  be  disintegration  prod- 
ucts of  leucocytes,  remnants  of  primitive  erythro- 
blastic  nuclei,  and  extrusion  processes  of  large  bone 
marrow  cells. 


.-0. 


A  , 


•        • 


• 


' 


10 


11 


12 


:.-W* 


13 


THR  Ri.non  CF.T.T.S. 


15 


6i 


THE  BLOOD  CELLS 


1.  Normal  red  cells. 
Achromic  red  cells. 
Blood  platelets. 

2.  Macrocyte. 
Microcytes. 

3.  Poikilocytes. 

4.  Stippled    and     basophilic 

cells. 

5.  Normoblasts. 
Megaloblas?. 

6.  Cells  containing  "  Howell- 

Jolly  "  bodies. 
Reticulated  cell. 

7.  Tertian  malaria. 


8.  Quartan  malaria. 

9.  Estivo-autumnal  malaria. 

10.  Poly  nuclear  neutrophile. 

1 1 .  Small  lymphocytes. 
Large  mononuclear  cell. 

12.  Mast  cell. 
Eosinophile. 

13.  Neutrophilic  myelocytes. 

14.  Basophilic  myelocyte. 
Eosinophilic  myelocyte. 

15.  Polynuclear        leucocytes 

containing  Dohle's  in- 
clusion bodies  (stained 
with  methyleneblue). 


63 

The  most  important  types  of  abnormal  red  cells 
are  the  following: 

1.  Microcytes.     Cells  smaller  than  normal. 

2.  Macrocytes.      Cells  larger  than  normal. 

3.  Poikilocytes.     Cells  of  distorted  shape. 

4.  Achromic    Cells.     Pale    cells    with    very    little 
coloring  matter  in  the  center  of  the  cell,  indicating  a 
deficiency  in  hemoglobin. 

5.  Polychromatophilic  Cells.     Cells  which  show  a 
tendency  to  take  the  basic  portion  of  the  stain,  and 
thus  appear  of  a  bluish  or  a  bluish  gray  color. 

6.  Stippled    Cells.     Cells    containing    many    fine 
dark  staining  granules. 

7.  Normoblasts.     Nucleated  cells,   the  embryonic 
form  of  red  blood  cells.     These  cells  may  have  round 
nuclei  or  may  have  karyorrhectic  or  multiple  dividing 
nuclei.     They    may    be    basophilic    and    stippled    or 
may  take  the  stain  like  a  normal  red  cell. 

Megaloblasts.     Cells  of  somewhat   the  same  ap- 
pearance as  the  preceding,  only  4  or  5  times  as  large. 

8.  Skeined  Forms.     Cells  which  when  stained  with 
brilliant  cresyl  blue,  show  a  skeined  or  reticulated 
appearance  of  the  protoplasm.     They  may  occur  in 
any  anemia,  and  a  few  are  present  in  normal  blood, 
but  they  are  especially  numerous  in  chronic  family 
(hemolytic)  jaundice.     The  technique  of  staining  is 
as  follows :  To  5  c.c.  of  a  saturated  solution  of  brilliant 
cresyl  blue  in  .85  per  cent  salt  solution,  add  5  c.c.  of 
.85  per  cent  salt  solution  and  2  c.c.  of  a  2  per  cent 
sodium  oxalate  solution.     Filter.     A  centrifuge  tube 
is  now  nearly  filled   with   this  mixture,   and   a  few 
drops  of  blood  obtained  from  the  ear  are  added.     The 
whole  is  centrifuged  for  a  few  moments,  washed  once 


65 

with  .85  per  cent  salt  solution,  and  a  smear  is  made 
from  the  sediment  of  blood  in  the  bottom  of  the 
centrifuge  tube.  The  usual  tendency  is  not  to  get 
the  saturated  solution  of  cresyl  blue  strong  enough; 
other  than  this  there  are  no  difficulties  in  the  tech- 
nique. 

9.  Howell- Jolly  Body  Containing  Forms.  Cells 
which  contain  one  or  more  small  black  dots,  known  as 
"  Howell-Jolly  "  bodies.  These  bodies  are  probably 
portions  of  the  nucleus  of  the  parent  normoblast,  and 
occur  especially  in  the  blood  of  pernicious  anemia 
patients  after  splenectomy  has  been  performed.  All 
of  these  abnormal  forms  may  occur  in  severe  anemias. 

Secondary  anemia  is  characterized  by  a  low  color 
index,  therefore  considerable  achromia.  There  may 
be  a  good  deal  of  tendency  to  polychromatophilia 
and  stippling,  with  moderate  variations  in  size  and 
shape  (anisocytosis  and  poikilocy  tosis) .  Normo- 
blasts  and  skeined  forms  may  occur.  It  is  not 
characteristic  of  the  blood  in  secondary  anemia  to 
have  extreme  anisocytosis  and  poikilocytosis,  and  it  is 
extremely  rare  to  find  megaloblasts. 

Pernicious  anemia  is  characterized  by  a  high  color 
index,  therefore  there  is  usually  no  achromia.  Certain 
special  characteristics  of  the  morphology  of  the  red 
cells  in  pernicious  anemia  are: 

1.  A    tendency    to    extreme    variations    in    size. 
Many  very  small  cells  will  be  seen  as  well  as  a  great 
many  very  large  ones.     The  general  tendency  is  to 
the  production  of  large  cells,  and  the  occurrence  of 
many  very  large  cells  is  almost  diagnostic  of  per- 
nicious anemia. 

2.  A  tendency  to  extreme  distortions  and  varia- 


67 

tions  in  shape.  Many  elongated  and  pear-shaped 
forms  are  likely  to  occur. 

3.  The  occurrence  of  megaloblasts.  It  is  rare  to 
find  megaloblasts  in  a  blood  of  secondary  anemia. 

Chlorosis  is  characterized  by  a  very  low  color  in- 
dex, with  consequently  a  great  deal  of  achromia. 
There  is  little  tendency  to  anisocytosis  and  poikilo- 
cytosis,  and  nucleated  forms  are  rare. 


THE  WHITE  BLOOD    CORPUSCLES 

The  following  varieties  of  white  blood  corpuscles 
occur  normally. 

1.  Polynuclear  neutrophiles   constitute   about   70 
per  cent  of  the  white  blood  cells.     They  are  two  or 
three  times  the  size  of  a  red  blood  cell,  and  have 
irregularly  shaped  nuclei,  with  granular,  lilac  staining, 
neutrophilic  protoplasm. 

2.  Lymphocytes  make  up  about  25  per  cent  of  the 
white  cells.     Their  usual  size  is  a  little  larger  than 
that  of  a  red  blood  cell,  although  there  is  considerable 
variation.     Very    large    forms    occur    in    abnormal 
bloods,  especially  in  certain  cases  of  acute  lymphatic 
leukemia.      The    nucleus    of    a    lymphocyte    stains 
dark  purple,  is  usually  round  or  oval,  or  occasionally 
indented,  and  is  very  clean-cut  in  its  outline.     The 
protoplasm  is  scanty,  showing  usually  as  a  narrow 
ring  around  the  nucleus.     It  stains  light  blue,  and  is 
usually     homogeneous,     although     sometimes     small 
reddish  "  azur  "  granules  are  seen  in  it. 

3.  Large    mononuclear   and   "  transitional "   cells 
make  up  from  3  to  5  per  cent  of  the  white  blood  cells. 
It   is   best   to   classify   them   together.     Their   exact 


69 

status  is  not  definite,  but  it  is  probable,  although  not 
certain,  that  they  represent  one  and  the  same  cell, 
in  different  stages  of  development.  The  large  mono- 
nuclears  are  a  little  larger  than  the  polynuclear 
neutrophiles,  have  a  single  round,  oval,  or  indented 
nucleus,  which  takes  the  stain  rather  poorly,  and* a 
wide  zone  of  basophilic,  non-granular  protoplasm. 
These  cells  may  sometimes  be  confused  with  lympho- 
cytes. The  principal  points  of  differentiation  are  that 
the  lymphocytes  are  more  intensely  basophilic  and 
deeply  stained  than  are  the  large  mononuclears,  are  a 
good  deal  more  clean-cut  and  regular  in  outline,  and 
do  not  have  such  a  wide  zone  of  protoplasm  around 
the  nucleus.  The  "  transitional  "  cells  are  like  the 
large  mononuclears,  except  that  the  nucleus  is  in- 
dented or  horseshoe  shaped,  and  there  may  be  a  few 
neutrophilic  granules  in  the  protoplasm.  They  are 
called  transitional  cells,  because  they  were  formerly 
thought  to  be  an  intermediate  stage  in  the  develop- 
ment of  the  polynuclear  leucocyte.  The  present  view 
is  that  they  have  nothing  whatever  to  do  with  the 
polynuclear  leucocytes. 

4.  Eosinophiles  are  usually  about  the  size  of  a 
polynuclear  neutrophile  and  constitute  about  2  to  4 
per  cent  of  the  total  number  of  white  cells.  The 
nucleus  has  the  same  shape  as  that  of  the  neutrophile, 
but  is  likely  to  appear  a  little  bluer  and  lighter  in 
color.  The  protoplasm  of  these  cells  is  filled  with 
large,  round,  coarse  red  granules  which  take  the  acid 
portion  of  the  stain.  Sometimes  if  the  diluted  stain 
has  been  left  on  too  long  the  granules  in  the  protoplasm 
of  the  polynuclear  neutrophiles  may  appear  reddish, 
but  they  are  not  nearly  so  large,  red  or  sharply  de- 


fined  as  those  in  the  eosinophiles,  and  there  should  be 
no  difficulty  in  differentiating  the  two  types  of  cells. 

Mast  cells  (polynuclear  basophiles)  are  cells  the  size 
of  the  eosinophiles,  but  they  show  an  especial  affinity 
for  the  basic  part  of  the  stain.  The  nuclei  are  like 
those  of  the  polynuclear  neutrophiles,  except  that  they 
usually  stain  a  little  more  deeply.  The  protoplasm 
is  filled  with  large,  dark  purplish  granules.  Mast 
cells  form  about  .5  to  I  per  cent  of  the  total  number  of 
white  corpuscles.  They  have  no  particular  signifi- 
cance. 

ABNORMAL   CELLS 

Myelocytes.  The  myelocytes  are  the  primitive 
forms  from  which  the  polynuclear  neutrophiles, 
basophiles  and  eosinophiles  are  derived.  They  do 
not  occur  in  normal  adult  blood,  but  may  be  seen  in 
certain  blood  diseases,  especially  myelogenous  leu- 
kemia. They  vary  a  good  deal  in  size,  sometimes 
being  a  little  smaller,  sometimes  being  a  little  larger 
than  the  common  potynuclear  neutrophile.  Three 
types  of  myelocytes  are  recognized : 

1.  Neutrophilic    Myelocytes.     These    cells    stain 
rather  faintly,  are  not  very  sharp  in  outline,  and  have 
a  large  round  or  oval  or  occasionally  a  kidney-shaped 
nucleus,    and    a    neutrophilic    granular    protoplasm. 
They  are  differentiated  from  the  other  neutrophilic 
cells  by  the  shape  of  the  nucleus,  and  from  the  large 
mononuclears  by  their  granular  neutrophilic  proto- 
plasm. 

2.  Eosinophilic  Myelocytes  are  mononuclear  cells 
similar  to  the  preceding,  with  many  eosinophilic  gran- 
ules scattered  through  the  protoplasm. 


73 

3-  Basophilic  Myelocytes  are  similar  to  those  of 
the  eosinophilic  form,  except  that  the  granules  in  the 
protoplasm  are  basophilic. 

THE   BLOOD   IN  INFANCY 

The  essential  fact  to  remember  about  the  blood  in 
infancy  is  that  it  tends  more  closely  to  resemble 
embryonic  blood  than  adult  blood  does,  and  that  for 
this  reason,  certain  cells,  such  as  myelocytes  and 
primitive  erythrocytes  (normoblasts  and  megalo- 
blasts)  may  appear  in  the  blood  of  an  infant  without 
having  the  same  significance  that  they  would  have  in 
the  blood  of  an  adult.  In  the  anemias  of  infancy, 
the  blood  tends  to  revert  to  its  primitive  form,  and 
comparatively  slight  causes  may  produce  an  enormous 
change  in  its  constitution,  with  the  appearance  of 
many  abnormal  forms  of  cells. 

QUANTITATIVE  DIFFERENCES 
(Morse:  Case  Histories  in  Pediatrics) 

Hemoglobin.  The  hemoglobin  varies  between  100 
and  125  per  cent  during  the  first  3  or  4  days  of  life; 
it  then  drops  to  the  minimum  of  60  per  cent  at  three 
weeks,  after  which  it  gradually  rises  to  70  per  cent 
at  six  months.  It  remains  at  this  point  during  the 
rest  of  the  first  two  years,  after  which  it  slowly  rises, 
reaching  the  adult  standard  at  about  6  years. 

Red  Blood  Cells.  During  the  first  few  days  of  life 
the  red  cells  number  6,000,000  to  7,500,000  per 
cubic  millimeter,  then  the  count  rapidly  falls  to  the 
normal  infantile  limit  of  about  5,500,000  which  it 
reaches  at  about  two  weeks.  During  the  rest  of  in- 
fancy the  blood  count  remains  at  about  this  figure, 


75 

and  gradually  diminishes  during  early  childhood, 
reaching  the  adult  standard  at  six  years. 

White  Blood  Cells.  During  the  first  few  days  of 
life  there  is  a  marked  increase,  sometimes  up  to 
36,000.  The  count  rapidly  drops  to  12,000  or  14,000, 
where  it  remains  during  the  first  six  months.  The 
normal  limits  during  the  rest  of  infancy  are  between 
10,000  and  12,000,  and  the  number  from  this  time  on 
is  approximately  the  same  as  for  the  adult,  7000  to 
10,000. 

In  young  children  there  is  a  relatively  greater  per- 
centage of  lymphocytes  and  a  smaller  percentage  of 
polynuclear  cells.  The  following  table  taken  from 
Chapin  and  Piseks'  "  Diseases  of  Children,"  shows  the 
percentages  for  different  ages. 

Polynuclears        Mononuclears 

Year  %  % 

i 35  53 

2 38  5i 

3 • 42  47 

4 47  4i 

5 52  39 

6. 52  37 

7 *  53  35 

8 54  33 

9 55  3i 

10 .' 60  30 

MALARIAL  PARASITES 

In  the  examination  for  malarial  parasites,  the 
blood  is  stained  with  Wright's  stain,  as  in  making  an 
ordinary  blood  smear,  and  if  the  parasites  are  present, 
they  may  be  easily  recognized.  Sometimes,  however, 
it  takes  a  long  and  patient  search  to  find  them.  By 
beginners,  artefacts  or  blood  platelets  lying  on  red 
blood  cells  are  likely  to  be  mistaken  for  parasites,  but 


77 

if  there  is  any  doubt  whatever  about  the  body  seen 
being  a  parasite,  it  is  probably  not  one,  for  they  stain 
very  prettily,  and  stand  out  against  the  reddish  back- 
ground of  the  red  blood  cell  in  a  very  clean-cut  manner. 
The  protoplasm  of  the  malarial  parasite  stains  light 
blue  and  always  contains  one  or  more  red  granules. 

Tertian  Malaria  (Plasmodium  Vivax)  appears  first 
in  the  red  cell  as  a  small  ring-like  body,  which  soon 
becomes  pigmented,  and  enlarged  so  greatly  that  the 
infected  red  cell  may  be  swollen  to  three  or  four 
times  its  normal  size,  with  only  a  thin  ring  of  proto- 
plasm showing  around  the  body  of  the  parasite. 

Quartan  Malaria  (Plasmodium  Malaria)  starts  as  a 
small  ring-shaped  body,  soon  becoming  larger  and 
pigmented,  as  does  the  tertian.  In  the  quartan  para- 
site the  pigment  granules  are  more  likely  to  be  ar- 
ranged around  the  periphery  of  the  organism,  whereas 
in  the  tertian  they  are  distributed  all  through  it. 
The  principal  point  of  differentiation  between  the 
two  forms  is  that  red  cells  infected  with  the  quartan 
form  do  not  swell  to  the  large  size  attained  by  those 
containing  the  tertian  parasite,  usually  remaining 
about  the  normal  size,  or  even  shrinking  a  little. 

Estivo  Autumnal  Malaria  (Plasmodium  Falcipa- 
rum).  The  estivo-autumnal  form  appears  in  the 
red  cells  first  as  a  very  small  ring-shaped  body  much 
like  the  ring  forms  of  the  tertian  and  quartan,  only 
smaller.  The  ring  is  thicker  at  one  side  than  the 
other,  thus  giving  it  the  so-called  "  signet  ring  "  ap- 
pearance. The  last  stage  of  the  estivo-autumnal 
parasite  may  occur  in  the  characteristic  "  crescent " 
shape,  which  easily  differentiates  it  from  the  tertian 
and  quartan  forms. 


79 
DOHLE'S  LEUCOCYTIC   INCLUSION   BODIES 

These  bodies  are  small  coccus  or  bacillus-shaped 
bodies  occurring  in  the  polynuclear  leucocytes  in  a 
number  of  diseases,  especially  in  scarlet  fever,  and 
were  first  described  by  him  in  1911.  They  may  be 
stained  with  the  ordinary  Loeffler's  methylene  blue, 
but  the  best  stain  for  them  is  Granger  and  Pole's 
modification  of  Manson's  stain,  prepared  as  follows: 
methylene  blue  1.5  grams;  absolute  alcohol  10  c.c.; 
5  per  cent  aqueous  solution  of  phenol  100  cc.  Methyl 
alcohol  is  used  as  a  fixative,  it  being  sufficient  to 
dip  the  blood  smear  into  the  alcohol,  wash  with  water 
and  immediately  stain.  With  this  stain  the  inclu- 
sions stain  a  deep  blue,  the  cell  nucleus  a  deep  blue, 
and  the  cell  protoplasm  a  pale  homogeneous  blue. 

The  inclusion  bodies  have  the  following  signifi- 
cance : 

1 .  They  are  present  in  a  majority  of  cases  of  scarlet 
fever  up  to  the  tenth  day  of  the  disease;   in  nearly 
all  cases  before  the  fourth  day. 

2.  They  are  not  specific  for  "scarlet  fever,  being 
found  in  a  number  of  the  infections,  most  particularly 
erysipelas,  sepsis,   pneumonia  and   tonsillitis.     They 
are  more  likely  to  be  found  in  diseases  with  which 
the  streptococcus  is  associated. 

3.  They  have  the  following  diagnostic  value :  If  they 
are  not  found  in  a  doubtful  case  which  has  a  rash 
and  a  marked  fever,  the  case  is  probably  not  one  of 
scarlet  fever. 

4.  They  are   probably  in   the  nature   of   a   reac- 
tion of  injury  of  the  cell  nuclei,  caused  by  bacteria 
toxins,  and  are  small  fragments  broken  off  from  the 
nuclei. 


8i 


WIDAL   SERUM   REACTION  FOR  TYPHOID 

The  ear  is  punctured  and  a  few  drops  of  blood  are 
allowed  to  run  into  a  small  test  tube.  This  is  al- 
lowed to  stand  until  the  clot  and  the  serum  have 
separated.  Now  place  9  drops  (platinum  loop)  of  an 
active  motile  twelve  to  twenty-four  hour  old  culture 
of  the  bacillus  typhosus  on  one  end  of  a  glass  slide, 
and  add  one  drop  of  the  serum,  mixing  well  with  the 
platinum  loop.  Place  four  drops  of  water  at  the 
other  end  of  the  slide,  and  then  add  to  it  one  drop  of 
the  I  to  10  dilution  which  has  already  been  made, 
making  a  dilution  of  I  to  50.  Cover  with  cover  glasses 
and  let  stand  one  hour.  Controls  should  be  made  by 
the  same  method  as  given  above,  except  omitting  the 
blood  serum.  If  the  reaction  must  be  done  with 
dried  blood  (as  in  the  board  of  health  outfits)  add  a 
drop  or  two  of  water  to  the  dried  blood  and  proceed 
as  before.  Widal's  reaction  is  positive  when  there  is 
complete  agglutination  and  loss  of  motility  in  an 
hour,  in  the  I  to  50  dilution.  .  The  performance  of 
the  test  is  very  easy,  but  it  is  sometimes  hard  to  know 
whether  to  call  a  reaction  positive  or  not.  Assurance 
in  this  can  come  only  after  having  performed  a  few. 

A  and  B  para  typhoid  (done  the  same  as  typhoid). 

The  Widal  reaction  appears  usually  only  after  the 
first  week  of  the  disease,  and  may  persist  for  years  in 
the  blood  of  patients  who  have  had  typhoid  fever. 

BLOOD   FRAGILITY  TEST 

A  determination  of  the  resistance  of  the  red  blood 
cells  to  hypotonic  salt  solution  is  sometimes  of  value 
in  the  diagnosis  of  "  chronic  family  jaundice  "  (hemo- 


83 

lytic),  and  especially  in  the  differential  diagnosis  of 
jaundice  due  to  this  disease  and  that  due  to  obstruc- 
tion of  the  bile  passages,  such  as  occurs  in  cases 
of  gallstones,  cancer -of  the  pancreas,  etc.  The  red 
cells  in  hemolytic  jaundice  show  a  lessened  resistance 
to  hypotonic  salt  solution;  in  obstructive  jaundice  an 
increased  resistance.  The  method  used  by  the  writer 
is  as  follows: 

About  6  c.c.  of  blood  is  drawn  from  the  arm  with  a 
needle  and  glass  syringe.  This  is  transferred  to  a 
test  tube  half  full  of  0.5  per  cent  sodium  citrate  solu- 
tion in  0.9  per  cent  sodium  chloride.  The  tube  is 
then  inverted  two  or  three  times  to  insure  proper 
mixing.  As  soon  as  possible  (certainly  within  three 
hours)  the  blood  is  centrifuged  and  the  cells  washed 
twice  with  0.7  per  cent  sodium  chloride.  As  much  of 
the  supernatant  fluid  as  possible  is  drawn  off  with  a 
pipet,  and  the  remaining  blood  cells  are  used  in  the 
test,  without  further  dilution.  The  hypotonic  sodium 
chloride  solutions  are  made  up  from  a  I  per  cent  solu- 
tion of  chemically  pure  sodium  chloride  and  distilled 
water.  The  solutions  run  in  strength  from  0.70  to 
0.175  Per  cent,  and  are  kept  in  tightly  corked  100  c.c. 
bottles.  Exactly  I  c.c.  of  each  one  of  these  solutions 
is  drawn  off  in  a  pipet,  and  placed  in  series  of  small 
test  tubes;  0.05  c.c.  of  the  blood  cells  is  then  run  into 
each  tube,  from  a  small  accurately  graded  pipet,  each 
tube  is  inverted  twice  and  allowed  to  stand  two  hours 
at  room  temperature;  at  the  end  of  this  time  the 
tubes  are  read.  As  initial  hemolysis  take  the  point 
at  which  there  is  the  first  tinge  of  pink  in  the  salt 
solution;  as  complete  hemolysis  the  point  at  which 
there  can  no  longer  be  seen  any  sediment  of  blood 


cells  in  the  bottom  of  the  tube.     The  average  points 
of  hemolysis  as  obtained  by  this  method  are: 


Normal  blood. ...     .457  (initial) 

Secondary  anemia    .475  (initial) 

Pernicious  anemia    .  477  (initial) 
Chronic  family  (hem- 

olytic)  jaundice     .600  (initial) 
Obstructive  jaun- 
dice   400  (initial) 


3.40  (complete) 
.322  (complete) 
.322  (complete) 

.400  (complete) 
.225  (complete) 


HEMOLYSIS    TEST 

(To  Determine  the  Compatibility  of  Donor's  and  Recipient's 
Blood  in  Transfusion) 

Donor.  Secure  two  samples  of  blood  of  5  c.c.  each, 
from  the  arm  vein.  One  of  these  samples  is  placed 
in  a  dry  test  tube  and  allowed  to  clot  (to  obtain  the 
serum),  the  other  sample  is  placed  in  a  test  tube  half 
full  of  .5  sodium  citrate  in  90  per  cent  sodium  chloride 
(to  prevent  clotting). 

Recipient.  The  same  is  done  'with  the  recipient's 
blood.  The  test  is  carried  out  as  follows  (Lindeman) : 
'  The  red  blood  cells  of  recipient  and  donor  are  washed 
three  times  with  normal  saline;  variable  quantities  of 
recipient's  serum  are  placed  in  three  separate  small 
test  tubes.  To  each  of  these  is  added  0.25  c.c.  of  a 
2%>er  cent  suspension  in  normal  saline  of  washed 
blood  cells  of  the  donor.  The  same  is  done  with  the 
donor's  serum  and  the  recipient's  cells.  Controls  are 
made  of  donor's  serum  and  donor's  cells  —  recipient's 
serum  and  recipient's  cells.  Controls  are  also  made 
with  donor's  cells  in  normal  salt  solution  and  recip- 


87 

ient's  cells  in  normal  salt  solution.  The  total  volume 
in  each  tube  is  raised  with  normal  saline  to  0.5  c.c. 
The  test  tubes  are  incubated  in  a  water  bath  for 
a  period  of  two  hours,  and  readings  are  made.  They 
are  then  set  in  an  icebox  over  night  and  readings 
are  again  made  the  following  morning.  When  the 
case  is  urgent  the  icebox  test  is  eliminated.  The 
icebox  test  should  be  eliminated  only  when  absolutely 
necessary  by  the  extreme  condition  of  the  patient 
where  time  is  the  important  factor.  When  the 
amount  of  blood  taken  from  the  patient  for  tests  is 
small,  only  0.25  c.c.  of  serum  is  used  and  controls  of 
patient's  serum  are  eliminated." 


COAGULATION  TIME 
(Method  of  Lee  and  White) 

This  is  a  very  simple  and  fairly  accurate  method. 
It  is  performed  as  follows:  One  cubic  centimeter  of 
blood  (approximately)  is  withdrawn  from  the  arm 
vein  by  a  small  needle  and  syringe,  both  of  which 
have  previously  been  washed  with  normal  salt  solu- 
tion, and  is  put  into  a  small  tube  of  about  8  mm.  in 
diameter,  which  has  also  been  previously  washed  in 
normal  salt  solution.  The  time  of  withdrawal  is  ac- 
curately noted ;  and  the  tube  is  inverted  gently  every 
30  seconds  until  the  blood  will  no  longer  run  down 
the  sides  of  the  tube,  but  remains  in  the  bottom  of 
the  tube  in  a  solid  clot.  This  is  the  end  point.  By 
this  method  the  coagulation  time  for  normal  blood  is 
from  4  to  8  minutes. 


89 
OBTAINING  BLOOD  FOR  CULTURES,  ETC. 

At  the  present  day  there  are  so  many  serological 
blood  tests  and  cultures  being  made,  that  every 
practitioner  should  be  able  to  withdraw  the  necessary 
amount  of  blood  from  the  veins  with  the  least  pos- 
sible discomfort  to  the  patient.  A  few  suggestions 
may  be  of  service. 

Do  everything  as  quickly  as  you  can;  it  irritates  the 
patient  to  see  you  fussing  around  with  your  needles 
and  syringes. 

Apply  a  turniquet  of  small  rubber  tubing  to  the 
upper  arm,  tightly  enough  to  make  the  veins  of  fhe 
elbow  stand  out,  but  not  tightly  enough  to  stop  the 
pulse  at  the  wrist. 

Have  the  patient's  arm  resting  on  a  table.  Use  a 
5  or  10  c.c.  all  glass  syringe,  with  a  small  needle,  it  is 
useless  to  torment  the  patient  with  a  large  one. 
Wash  off  the  arm  at  the  bend  of  the  elbow  gently  with 
a  little  alcohol,  with  the  fingers  of  the  left  hand  hold 
the  skin  tightly  on  the  stretch,  and  insert  the  needle 
with  the  right,  taking  care  not  to  run  it  in  too 
deeply. 

Now  gently  and  slowly  pull  the  piston  back,  and 
if  the  needle  is  in  the  vein  and  the  syringe  is  tight, 
there  will  be  no  difficulty  in  getting  as  much  blood 
as  desired.  Use  a  sharp  needle,  and  be  sure  that  it 
fits  the  syringe,  and  that  the  syringe  is  tight.  If  it 
is  not  you  will  be  troubled  with  air  bubbles. 

In  the  case  of  a  very  fat  patient  where  the  veins 
cannot  be  seen,  the  small  needle  is  inserted  in  the 
same  way,  and  gently  prodded  around  in  all  directions 
until  a  vein  is  struck  (most  of  the  pain  is  in  the  first 
skin  puncture). 


91 

In  the  case  of  babies  the  veins  of  the  scalp  or  the 
jugulars  may  be  used.  A  practiced  operator  can 
secure  enough  blood  for  a  Wassermann  in  a  very  few 
seconds,  and  can  save  the  patient  a  great  deal  of  dis- 
comfort by  obtaining  the  required  amount  in  the 
shortest  possible  time. 


CHAPTER  III 
FECES 

Color.     The  most  important  abnormal  colors  are : 

1 .  Grayish  black  —  due  to  the  ingestion  of  iron  or 
bismuth  compounds. 

2.  Tarry  black,  from  digested  blood  (seen  in  bleed- 
ing cancer  or  ulcer  of  the  stomach). 

3.  Green  • —  from  calomel. 

4.  Red  —  from  blood  coming  from  the  rectum  or 
low  down  in  the  large  intestine. 

5.  Clay  colored  —  from  an  excess  of  fat  and  an 
absence  of  bile  (obstructive  jaundice). 

Reaction.  Normally  neutral  or  slightly  acid  or 
alkaline;  an  excessively  acid  stool  is  due  to  carbo- 
hydrate fermentation,  a  strongly  alkaline  one  to  pro- 
tein putrefaction. 

Consistency  and  Form.  The  normal  may  vary  a 
good  deal.  The  longer  a  stool  stays  in  the  colon  or 
rectum,  the  harder  and  drier  it  becomes,  owing  to 
the  absorption  of  water  from  it  through  the  intestinal 
wall.  In  abnormal  stools  all  degrees  of  consistency 
may  be  seen,  from  the  very  watery  thin  ones  occurring 
in  cholera,  to  the  round,  hard,  bullet-like  ones  seen 
in  certain  cases  of  constipation  with  an  impacted 
rectum. 


93 


95 

MACROSCOPIC   EXAMINATION 

Spread  out  a  small  amount  of  feces  with  a  little 
water  on  a  plate. 

1.  Abnormal  food  residue  may  consist  of  cellulose 
or  meat  or  jelly-like  starch  remains. 

2.  Mucus.     Any  but  the  smallest  amount  of  mucus 
is  abnormal,   indicating  catarrh  or  irritation  some- 
where in  the  intestinal  tract.     Mucus  from  the  large 
intestine  is  usually  present  as  a  thin  coating  over  the 
outside  of  the  stool  —  that  from  the  small  intestine  is 
well  mixed  with  the  fecal  matter.     Do  not  confuse 
soft  food  residues  with  mucus. 

3.  Blood.     Blood  from  the  rectum  usually  appears 
as  bright  red  streaks  on  the  outside  of  the  stool,  that 
from  the  rest  of  the  lower  intestinal  tract  is  inti- 
mately mixed  with  the  stool,  and  gives  it  a  dull  brick 
color  —  or   may   appear   in    streaks    (as    in    amebic 
dysentery) .     Blood  from  the  upper  intestinal  tract  or 
stomach,  if  present  in  sufficient  amount,  gives  a  dark 
black  color  to  the  stool. 

4.  Pus  may  appear  as  yellowish  masses  or  streaks. 

5.  Shreds  of  intestinal  mucus  membrane  —  from 
ulcerative  disease  of  the  intestine. 

6.  Gallstones  usually  may  be  recognized  by  their 
hardness,  and  characteristic  shape,  with  facets. 

7.  Intestinal   sand   consists   of  small   granules   of 
gray  or  reddish-brown  gritty  material  occurring  rarely 
in  the  stools.     Its  origin  is  not  certain.     "  False  in- 
testinal sand  "  usually  consists  of  the  seeds  of  bananas, 
or  the  hard  portions  of  fruits,  covered  with  calcium 
salts.     Neither  variety  has  any  particular  practical 
significance. 


97 

INTESTINAL  PARASITES 
(Adapted  partly  from  Kilgore) 

The  most  common  intestinal  parasites  are: 

1.  Ascaris     lumbricoides    (the    common    "  round 
worm  ")    varies   in   length   from    15    to   40   cm.     It 
occurs  usually  in  small  numbers,  and  there  should  be 
no  difficulty  in  recognizing  it,  as  it  is  much  larger 
than  any  of  the  other  ordinary  round  worms  seen  in 
the  feces. 

2.  Oxyurus  vermicularis  (the  ordinary  pin-worm)  is 
a  small  worm  3  to  10  mm.  long,  and  usually  occurs  in 
the  rectum  or  colon. 

3.  Uncinaria    duodenalis    (hookworm)  is  8  to  1 8 
mm.   long.     The  buccal   cavity  has    three   pairs   of 
inward  curving  hook-like  teeth  (uncinaria  (necator) 
Americana  has  a  dorsal  and  a  ventral  pair  of  cutting 
plates  instead  of  hooks.) 

4.  Trichuris  trichiura   is  4   to   5   cm.  long,  two- 
thirds  of  the  length  appearing  as  a  whip-like  tail. 

5.  Taenia   saginata  (beef   tapeworm).      The  head 
is  1.5  to  2  mm.  in  diameter,  and  has  four  suckers,  but 
no  hooks.     The  ripe  segments  are  16  to  20  mm.  by 
5   to   7  mm.     The  uterus  has  a  multitude  of  fine 
branchings.     The    genital    openings    are    irregularly 
alternate  on  the  margin. 

6.  Taenia  solium  (pork  tapeworm)  is  very  rare  in 
America.      The  head  is  .6  to   I    mm.    in   diameter, 
and  has  four  suckers  on  the  sides,  and  on  the  end  a 
crown  of  22  to  32  hooks.     The  ripe  segments  are  9  to 
10  by  4  to  5  mm.     The  uterus  consists  of  a  large 
median  stem  with  but  7  to  10  coarse  branches,  each 
of  which  again  branches.     The  genital  openings  are 


99 

at  the  margin  and  alternate  from  side  to  side  with 
considerable  regularity. 

7.  Bothriocephalus    latus    (fish   tapeworm).     The 
head  is  I  mm.  broad  and  2  or  3  mm.  long,  is  flat, 
almond  or  spoon  shaped,  with  two  deep  grooves  at 
its  sides.     The  ripe  segments  are  10  to  15  by  3  to  4 
mm.     The  genital  opening  is  on  the  side,  not  the 
edge,  and  the  uterus  is  arranged  about  it. 

8.  Hymenolepis  nana  (Tsenia  nana)  is  most  com- 
mon in  Italy  and  Egypt,  but  is  occasionally  seen  in 
the  United  States.     It  is  a  small  worm,  only  8  to  25 
mm.  long,  and  .5  mm.  broad.     The  head  is  round  and 
has  4  suckers  and  24  to  28   hooklets.     They  may 
occur  in  the  stools  in  extraordinarily  large  numbers. 


CHEMICAL  EXAMINATION 

Blood.     Guaiac  test  (see  gastric  contents,  p.  127). 

Benzidin  T.est.  In  a  test  tube  place  a  small  pinch 
of  benzidin,  2  c.c.  of  hydrogen  peroxide,  and  a  few 
drops  of  glacial  acetic  acid.  Shake  well.  Rub  up 
with  a  glass  rod  a  small  portion  of  feces  in  another 
test  tube  in  5  c.c.  of  water,  and  heat  to  boiling. 
Pour  a  few  drops  of  mixture  No.  2  into  mixture  No.  I. 
If  blood  is  present,  a  blue-green  color  results.  This 
is  an  extremely  delicate  test,  and  is  of  no  value  un- 
less the  patient  is  known  to  have  been  on  an  abso- 
lutely meat  free  diet  for  two  or  three  days.  The 
writer  never  uses  this  test,  much  preferring  the 
guaiac  test,  which  is  delicate  enough  to  recognize 
blood  in  any  amount  of  practical  importance. 

Bile  (hydrobilirubin).  Rub  up  a  small  portion  of 
feces  in  a  mortar  or  evaporating  dish,  with  a  con- 


lor         :    :  --*;.„  ,^fj  ,  t 

centrated  aqueous  solution  of  corrosive  sublimate,  and 
let  it  stand  for  3  hours. 

A  brick  red  color  indicates  the  presence  of  bile. 

MICROSCOPIC   EXAMINATION 

For  microscopic  examination  a  small  portion  of 
feces  is  rubbed  up  with  a  little  water  on  a  glass  slide, 
and  examined  .first  with  the  low  and  then  with  the 
high-power  lens. 

i.   Food  Residue 

(a)  Fat.  Fat  may  exist  in  the  stool  as  fatty  acids, 
neutral  fat,  or  soaps;  it  occurs  most  commonly  as 
calcium  soap,  which  usually  looks  yellow  under  the 
microscope.  Normally  there  is  a  certain  amount  of 
soap  in  the  stools,  while  any  but  the  smallest  amount  of 
neutral  fat  is  abnormal.  Unstained  neutral  fat  ap- 
pears as  small  refractile  globules,  or  sometimes  with 
fats  of  high  melting  point,  as  irregular  flakes,  the  fatty 
acids  as  flakes  or  needle-like  or  plate-like  crystals, 
and  the  soaps  as  yellowish  masses  or  occasionally 
crystals.  Fat  is  best  seen  when  stained  with  an 
alcoholic  solution  of  Sudan  III.  A  drop  of  the  stain 
is  added  to  the  rubbed  up  feces;  neutral  fat  droplets 
stain  bright  red,  amorphous  fatty  acids,  if.  present, 
stain  a  light  red  —  crystalline  fatty  acids  and  soaps 
do  not  stain  at  all.  A  little  more  stain  and  a  drop  or 
two  of  glacial  acetic  acid  is  now  added,  and  the  slide 
is  gently  heated.  Neutral  fat  stays  as  it  was  before, 
soap  is  broken  down  to  fatty  acid  and  an  alkali,  and 
stains  in  bright  red  droplets,  fatty  acid  melts  and 
stains  in  bright  red  droplets. 


103 

Resume.  For  neutral  fat  and  amorphous  fatty 
acids,  stain  with  Sudan  III  alone;  for  total  fat  stain 
with  Sudan  III  +  acetic  acid  and  heat. 

(b)  Starch.     Stain    the    rubbed    up    feces   with    a 
drop  of  dilute  iodine  solution,  or  with  Lugol's  solution 
(IKI).     Undigested  starch  granules  stain  dark  blue, 
partially  digested  granules  stain  a  brownish  color. 
The   spores   of   certain   fungi   may  stain   blue  with 
iodine,  but  may  be  differentiated  from  starch  granules 
because  they  lack  the  characteristic  concentric  rings, 
and  are  smaller  and  usually  oval  instead  of  round. 
Certain  small  particles  of  cellulose  may  take  on  a 
dark  color  with  iodine,  but  may  be  differentiated  by 
their  irregular  shape. 

(c)  Meat  Residue  (muscle  fibers).     Meat  residue 
occurs  in  the  form  of  small  muscle  fibers,  which  ap- 
pear yellow.     Sometimes  these  look  very  much  like 
calcium  soaps,  but  they  may  be  differentiated  by  the 
fact  that  they  are  striated ;  soaps  are  not. 

(d)  Cellulose    is    the    fiber   structure   surrounding 
vegetable  cells.     Normally  a  certain   amount  of  it 
appears  in  the  feces,  and  may  be  easily  recognized  by 
its  cellular  arrangement.     With  iodine  it  may  stain 
a  dark  purplish  black,  or  a  dark  brown. 

Be  careful  not  to  confuse  round  or  oval  cellular 
remains  with  parasitic  ova;  the  ova  are  always 
more  clean-cut  and  symmetrical  than  any  cellulose 
cell. 

Unorganized  Matter.  Various  crystals,  such  as 
ammonium  magnesium  phosphate,  calcium  oxalate, 
calcium  sulphate,  cholesterin,  etc.,  occur  in  the  stools, 
but  are  of  little  or  no  practical  importance.  After 
the  administration  of  bismuth  salts,  irregular  crystals 


of  black  bismuth  suboxide  may  be  seen.     Iron  is 
passed  as  black  amorphous  granules. 

2.  Cellular  Elements 

(a)  Epithelial  Cells.     Normally  very  few  epithelial 
cells  appear  in  the  feces.     If  present  in  large  numbers 
they  indicate  an  inflammatory  condition. 

(b)  Pus.     A  few  leucocytes    may  be  found   in  a 
normal  stool,  but  are  hard  to  recognize  on  account  of 
being  partly  digested.     If  present  in  abnormal  num- 
bers they  may  come  from  inflammatory  disease  of 
the  intestine  itself,  or  may  come  from  a  collection 
of    pus   in   some   other   organ   perforating   into    the 
intestine. 

(c)  Blood  cells  are  not  commonly  seen  in  the  feces 
unless  there  is  fresh  blood  present  from  low  down 
in  the  intestinal  tract.     If  the  blood  comes  from  the 
upper  portion  of  the  tract  it  is  practically  always 
digested. 

3.  Parasites 

(a)  Bacteria.  The  bacteriology  of  the  stools  is  an 
enormous  subject  and  cannot  be  dealt  with  in  a  book 
of  this  sort.  Two  bacteriologic  examinations,  how- 
ever, which  are  of  importance  and  which  can  be  per- 
formed so  simply  that  they  are  of  value  in  ordinary 
clinical  routine  are  those  for  the  tubercle  bacillus  and 
for  the  "  gas  "  bacillus  (Bacillus  serogenes  capsu- 
latus) . 

Tubercle  Bacillus.  Mix  feces  and  water  together 
in  equal  parts  and  centrifuge.  Tubercle  bacilli,  if 


107 

present,  will  come  to  the  top  of  the  tube,  and  can  be 
stained  in  the  thin  scum  there.     (See  p.  159.) 

Gas  Bacillus  (Technique  used  at  the  Children's 
Hospital,  Boston). 

1.  Fill  a  fermentation  tube  and  a  test  tube  with 
concentrated   nitric    acid,  let   stand  3  minutes,  and 
empty  out  the  nitric  acid. 

2.  Rinse   both    tubes   with    hot    tap   water   until 
neutral  to  litmus  paper. 

3.  Place  a  small  bit  of   stool,  about  a  gram  of 
dextrimaltose  and  about    15  c.c.  of   hot   tap  water 
in    the    test  tube,    and  boil    vigorously  for    half   a 
minute. 

4.  Put  the  contents  of  the  test  tube  into  the  fer- 
mentation tube,  taking  care  that  it  is  filled  up  to  the 
top,  and  that  no  air  bubbles  remain  in  it. 

5.  Plug  the  tube  with  flamed  cotton  and  incubate 
for  24  hours. 

Gas  in  the  top  of  the  tube  indicates  that  the  gas 
bacillus  is  present,  in  greater  or  lesser  numbers,  de- 
pending upon  the  amount  of  gas«formed. 

(b)  Protozoa.  In  this  part  of  the  world  the  only 
three  protozoans  .of  importance  commonly  met  with 
in  the  feces  are  the  entameba  coli,  entameba  histo- 
lytica,  and  entameba  tetragenus.  Amebse  should  be 
examined  for  in  a  fresh  stool  which  has  been  passed 
into  a  vessel  containing  warm  water.  If  examined 
for  in  this  way,  while  still  warm,  they  can  often  be 
seen  moving  about  and  thrusting  out  their  character- 
istic pseudopodia,  which  serve  to  differentiate  them 
absolutely  from  any  other  cells  or  organisms  found 
in  the  stool. 


109 


fl»im .  °i  I  si  sit 

Hlll^i  1 111111 

^8°1^    S«3llll?1 


FROM  CABOT'S  PHYSICAL  DIAGNOSIS. 


Heterophyes 
heterophyes. 


Distomal 
felineum.j 


Dictocoeliuit! 
lanceolatum 


Bilharzia         Diplogonoporus  Bilharzia  Dibothrio-  BUharzia 

haematobium.  grand  is.  haematobium.         cephalus  latus.        haematobium. 


Ascaris  Oxyuris  Paragonimus  Taenia  nana..  Ascaris 

lumbricoides.        vermicularis.  westermani.  lumbricoides. 


Anchylostoma 
duodenale. 


Necator  Strongylus 

americana  subtilis. 


Strongyloides 
stercoralis 


DRAWINGS  OF  EGGS  OF  INTESTINAL  PARASITES. 
All  are  magnified  250.     (After  Looss.) 


Ill 

(c)  Ova  of  various  worms. 

Ascaris  lumbricoides.  These  eggs  are  usually 
easily  recognized  by  their  rough  bile-stained  envelope. 
The  protoplasm  is  unsegmented. 

Oxyurus  vermicularis.  These  eggs  are  small, 
smooth,  oval,  and  are  usually  rather  light  colored. 
They  are  more  likely  to  be  found  on  the  skin  about 
the  anus  than  in  the  feces. 

Trichiuris  trichiura.  May  be  easily  recognized  by 
the  characteristic  light  yellow  roundish  knobs,  one  on 
each  pole  of  the  egg.  These  eggs,  occur  often  in  the 
stools  of  people  who  are  perfectly  well;  the  parasites 
may  occasionally  cause  symptoms,  however. 

Necator  (Uncinaria)  americana  may  usually  be 
recognized  by  the  fact  that  when  seen  the  protoplasm 
is  likely  to  be  segmented.  Often  the  embryos  may 
be  seen  curled  up  within  the  egg. 

Taenia  saginata.     Usually  round  or  slightly  oval  - 
has  an  outer  and  an  inner  shell,  with  striations  be- 
tween the  two. 

Taenia  solium  is  very  similar* to  the  above;  it  is 
very  rare  in  America,  however. 

Hymenolepis  nana.  These  ova  are  a  little  larger 
than  the  preceding.  They  have  a  double  shell,  and 
the  space  between  the  inner  and  outer  shells  is  filled 
with  a  granular  substance,  and  is  not  striated. 

Bothriocephalus  latus.  Rather  a  large  egg,  larger 
than  the  preceding  three  varieties  of  tapeworm  eggs. 
They  have  a  lid  at  one  end  of  the  egg,  which  some- 
times may  be  open,  and  the  contents  of  the  egg  looks 
like  a  bunch  of  grapes. 


H3 
THE  STOOLS  IN  INFANCY 

The  examination  of  the  stools  in  infancy  is  of  the 
utmost  importance  in  determining  whether  the  baby 
is  digesting  his  food  well,  and  if  not,  to  what  particu- 
lar element  of  the  food  the  indigestion  is  due.  There 
is  no  absolute  standard  of  normality  for  an  infant's 
stool,  it  varies  so  much  according  to  the  composition 
of  the  food,  the  relation  between  the  different  ele- 
ments of  the  food,  the  nature  of  the  intestinal  bacteria, 
the  motility  of  the  intestine,  and  the  absorptive  and 
digestive  power  of  the  particular  baby  in  question. 

Number.  The  number  of  evacuations  varies. 
The  normal  should  not  be  over  four  in  the  twenty- 
four  hours.  Breast-fed  babies  are  likely  to  have 
more  than  are  bottle-fed  babies,  owing  to  the  high 
sugar  percentage  of  breast  milk,  but,  on  the  other 
hand,  breast-fed  babies  may  sometimes  be  extremely 
constipated.  Dextrimaltose  as  a  rule  is  constipating, 
maltose  is  laxative  —  and  in  general  the  higher  the 
sugar  percentage  is  in  the  food,  the  greater  will  be 
the  number  of  stools. 

Fermentative  and  infectious  processes  in  the  in- 
testine give  rise  to  an  increased  number  of  stools;  in 
fermentative  or  infectious  diarrhea  there  may  be  as 
many  as  twenty  or  thirty  movements  in  the  twenty- 
four  hours.  Nervous  influences  may  cause  an  in- 
creased intestinal  peristalsis,  and  hence  an  increased 
number  of  stools.  Sometimes  a  large  amount  of  in- 
soluble soaps  in  the  stools  causes  a  severe  constipation. 

Form  and  Consistency.  The  infant's  stool  is 
usually  unformed,  and  of  a  mushy  consistency. 
Formed  stools,  however,  may  be  normal.  Consti- 
pated stools  due  to  increased  soap  content  are  scyb- 


H5 

alous  and  crumbly.  The  longer  a  stool  stays  in  the 
rectum  the  harder  it  is  likely  to  be.  The  stools  of 
simple  indigestion,  or  of  indigestion  with  fermentation 
may  vary  all  the  way  from  a  consistency  that  is 
slightly  thinner  than  normal,  to  one  that  is  watery. 
A  common  type  of  stool  seen  is  of  the  consistency  of 
thin  scrambled  eggs,  with  many  small  white  fat 
curds  scattered  through  it.  Fat  curds  are  small,  soft, 
soluble  in  ether,  and  are  of  very  common  occurrence. 
Casein  curds  are  large,  smooth,  white  masses  from 
the  size  of  a  small  bean  to  that  of  a  large  one,  are  in- 
soluble in  ether,  and  become  very  hard  when  put 
into  formalin.  They  are  not  of  such  common  occur- 
rence as  the  fat  curds.  A  foamy,  bubbly  stool  .is 
due  to  fermentation  in  the  intestine,  usually  of 
carbohydrate,  but  sometimes  of  protein. 

Color.  The  color  varies  according  to  the  type  of 
food  the  baby  is  being  fed  on.  The  typical  breast- 
milk  stool  is  of  a  golden  yellow  color.  Most  stools 
are  usually  yellowish,  or  a  dull  yellowish  brown. 
Darker  brown  stools  are  usually-  due  to  an  increased 
protein  percentage  in  the  milk.  White  stools  are 
due  to  a  high  insoluble  soap  content.  A  stool  which 
is  green  when  passed  is  almost  always  abnormal,  and 
is  usually  due  to  a  sugar  fermentation.  The  green 
color  is  due  to  the  presence  of  biliverdin.  Normally 
bile  is  present  in  the  stools  as  bilirubin,  which  is 
colorless,  but  under  the  influence  of  intestinal  fer- 
mentation it  is  oxidized  to  the  green  biliverdin.  A 
stool  which  turns  green  on  the  outside  after  standing 
in  the  air  is  not  abnormal.  Black  stools  are  due  to 
the  ingestion  of  bismuth  or  iron  salts,  or  rarely  (in  a 
baby)  to  digested  blood. 


Reaction.  The  determination  of  the  reaction  to 
litmus  paper  of  abnormal  stools  is  of  the  utmost  im- 
portance in  telling  to  what  food  component  the  in- 
digestion is  due.  Normal  stools  may  be  slightly 
acid,  neutral,  or  slightly  alkaline  —  a  strong  acidity 
or  alkalinity  usually  indicates  abnormality.  Under 
normal  conditions  the  reaction  of  the  stool  depends 
upon  the  relation  between  the  fat  and  the  protein, 
a  high  fat  percentage  tending  to  produce  acidity. 
The  stools  of  normal  breast-fed  babies  are  likely  to 
be  acid  on  this  account  for  there  is  a  relatively 
high  fat  percentage  in  breast  milk.  Under  abnormal 
conditions  of  fermentation,  however,  the  acid  re- 
action of  the  stool  is  due  to  a  high  sugar  percentage  in 
the  milk. 

In  the  infant's  intestine  two  processes  are  always 
working  against  each  other:  decomposition  of  carbo- 
hydrate food,  with  acid  end  products,  and  decompo- 
sition of  protein  food,  with  alkaline  end  products. 
Normally  these  two  processes  just  about  balance  each 
other  —  when  one  is  greatly  in  preponderance  trouble 
usually  results,  and  a  diarrhea  ensues,  due  to  the 
irritating  action  upon  the  intestine  of  the  too  strongly 
acid  or  alkaline  end  products.  Strongly  acid  stools 
due  to  fermentation  of  carbohydrate  are  very  com- 
mon, occurring  in  the  common  fermentative  diarrhea 
that  one  sees  so  often  in  summer.  Strongly  alkaline 
stools  from  excessive  protein  decomposition  are  not 
so  common. 

Odor.  The  stools  of  a  breast-fed  baby  usually 
have  a  not  unpleasant  aromatic  odor.  A  high  protein 
percentage  in  the  food  causes  a  rather  cheesy  and 
sometimes  foul  odor.  A  high  sugar  percentage,  with 


119 

fermentation  of  a  part  of  the  sugar,  causes  an  acid 
odor,  sometimes  very  intense,  due  to  the  presence  of 
acetic  and  butyric  acids.  The  stools  in  infectious 
diarrhea  may  be  nearly  odorless,  or  acid,  or  foul 
smelling. 

Mucus.  Any  more  than  the  very  slightest  amount 
of  mucus  is  abnormal.  Mucus  may  occur  around  the 
outside  of  a  constipated  stool,  owing  to  its  hard 
character,  and  consequent  irritation  of  the  rectum. 
Mucus  occurs  almost  always  in  large  amounts 
in  the  stools  of  fermentative  .  diarrhea.  This  is 
because  of  the  great  irritant  action  of  the  volatile 
fatty  acids  of  sugar  fermentation  upon  the  intestine. 
Mucus  also  always  occurs  in  infectious  diarrhea. 

Mucus  stools  mixed  with  blood  streaks  may  occur 
in  intussusception. 

Blood.  Digested  blood  is  rarely  seen  in  the  stools 
of  infants.  Blood  is  usually  due  to  infectious  diar- 
rhea if  it  occurs  streaked  with  mucus  throughout  the 
stool,  or  it  may  occur  on  the  outside  of  the  stool  if  a 
fissure  of  the  anus  or  a  bleeding  rectal  polyp  is  present. 


MICROSCOPIC   EXAMINATION 

Fat.  Technique  is  the  same  as  for  adult  stools. 
(See  p.  101.) 

Neutral  fat  rarely  occurs,  except  in  very  small 
amounts.  Most  of  the  fat  residue  present  in  infant's 
stools  occurs  as  calcium  or  magnesium  soap,  and  nor- 
mally not  an  inconsiderable  amount  may  be  present, 
sometimes  as  high  as  a  fifth  of  the  weight  of  the  dried 
stool.  It  is  useless  to  try  to  tell  anybody,  except  in 
very  general  terms,  how  much  fat  should  be  present 


121 

• 

in  a  normal  infant's  stool ;  every  observer  has  to  form 
a  standard  for  himself  by  repeated  examinations. 

In  "  soapy "  stools,  the  "  seifen  stiihle "  of  the 
Germans,  nearly  the  whole  stool  may  be  made  up  of 
soap,  and  under  the  microscope  the  whole  field  is 
composed  of  fat  globules  when  the  stool  is  treated 
with  Sudan  III,  acetic  acid  and  heat. 

Starch.  Technique  is  the  same  as  for  adult  stools. 
(See  p.  103.) 

Starch  residue  is  not  commonly  found  in  infants' 
stools  except  in  cases  where  too  much  starch  is  being 
fed.  The  occurrence  of  more  than  the  smallest 
amount  of  starch  in  the  stool  is  an  indication  for 
cutting  down  the  starch  in  the  diet. 

Remember  that  nearly  all  dusting  powders  used  on 
babies'  buttocks  contain  starch. 


CHAPTER   IV 
GASTRIC    CONTENTS 

I 
EXAMINATION  OF  THE  FASTING  CONTENTS 

The  fasting  contents  is  obtained  through  the 
stomach  tube  in  the  morning,  when  no  food  or  water 
has  been  taken  into  the  stomach  since  the  previous 
night. 

GROSS  EXAMINATION 

(a)  Amount.     Usually   the  amount  is  small  —  10 
or  15  c.c.     Anything  over  50  c.c.  is  distinctly  ab- 
normal,   indicating    stasis    or    too    profuse    gastric 
secretion. 

(b)  Consistency.     Normally  the  'fasting  contents  is 
thin  and  watery,  with  a  little  mucus.     An  excess  of 
mucus  or  an  increased  consistency  due  to  food  re- 
mains is  abnormal. 

(c)  Color.     The  normal  color  is  a  light  yellowish 
green,  or  colorless.     A  darker  green  color  indicates 
excessive  bile   (probably  from   retching  due   to   the 
passage  of  the  tube).     A  chocolate  or  "  coffee  ground  " 
color  usually  indicates  digested  blood.     Fresh  blood, 
when  present,  is  in  light  red  streaks. 

(d)  Food.     Any  macroscopic   food   residue   is   ab- 
normal, and  indicates  stasis,  of  a  lesser  or  greater 
degree,  depending  upon  the  amount. 

123 


125 

(e)  Odor.  Normally  there  is  very  little  odor  to  the 
fasting  contents;  if  there  is  fermentation,  the  char- 
acteristic odors  of  acetic  and  butyric  acids  may  be 
recognized. 

MICROSCOPIC   EXAMINATION 

(a)  Food  Residue. 

Starch.  Stain  with  dilute  iodine  solution,  or 
Lugol's  solution  (IKI).  The  starch  granules  stain 
dark  blue. 

Fat.  Stain  with  Sudan  III.  The  fat  globules  ap- 
pear red. 

Normally  there  may  be  a  very  few  microscopic 
particles  of  food  residue;  any  considerable  amount  of 
either  fat  or  starch  indicates  stasis. 

(b)  Blood.     Red  blood  cells  may  be  recognized  by 
their    characteristic    morphology.     Do    not    confuse 
them  with  yeasts. 

(c)  Pus.     Pus  is  very  rarely  found  in  the  gastric 
contents    (unless   it    has   been    swallowed    with    the 
sputum) .     Pus  cells  may  be  easily"  recognized  by  add- 
ing a  drop  of  acetic  acid  to  the  material  to  be  ex- 
amined, which  makes  the  characteristic  polynuclear 
nuclei  stand  out  sharply.     Pus  cells  seen  in  the  gastric 
contents  are  likely  to  be  partially  digested. 

(d)  Epithelial  Cells.     A  few  epithelial  cells  may  be 
present  in  the  fasting  contents.    An  excess  is  abnormal, 
indicating  gastritis. 

0)  Tumor  Cells.  Occasionally,  in  cases  where 
there  is  cancer  of  the  stomach,  small  pieces  of  cancer 
tissue  or  groups  of  cancer  cells  may  be  brought  up 
by  the  tube,  and  sometimes  are  of  great  assistance  in 
making  a  correct  diagnosis.  If  the  piece  of  tissue  is 


127 

large  enough  it  may  be  "  run  through  "  and  sectioned 
by  a  competent  pathologist,  and  an  exact  diagnosis 
of  the  sort  of  tumor  present  made. 
(/)  Organisms. 

1.  Sarcinae  are  occasionally  seen.     They  are  small 
cocci,  arranged  in  squares  or  tetrahedra,  and  have  a 
very  characteristic  appearance.     They  mean  stasis, 
but  are  rarely  found  when  there  is  no  free  hydro- 
chloric acid  present. 

2.  Yeasts.     Several    forms    of   yeasts   of   varying 
sizes  and  shapes  may  occur.     These  may  usually  be 
recognized  by  their  tending  to  show  buds. 

3.  Boas-Oppler  Bacilli.     These  are  very  large,  long 
Gram-positive  bacilli,  which  occur  commonly  in  the 
gastric  contents  of  patients  with  cancer  of  the  stomach, 
especially  if  there  is  stasis  and  lactic  acid  present. 
They  are  rare  in  non-malignant  disease  of  the  stomach. 


CHEMICAL  EXAMINATION 

(a)  Free  HC1.     A  drop  of  Top'fer's  reagent  (a  .5  per 
cent  alcoholic  solution  of  dimethyl-amido-azo-benzol) 
is  added  to  a  small  portion  of  the  fasting  contents. 
If  free  hydrochloric  acid  is  present  a  red  color  re- 
sults.    A  still  simpler  test  is  with  Congo  red  paper. 
If  a  drop  of  the  fasting  contents  is  put  upon  the  red 
paper,  the  presence  of  free  hydrochloric  acid  is  indi- 
cated by  the  production  of  a  dark  blue  color. 

(b)  Blood.     (Guaiac  Test.)     To  10  c.c.  of  gastric 
contents  (or  less  if  10  c.c.  is  not  available)  add  a  few 
drops  of  glacial   acetic  acid,   and    10  c.c.   of  ether. 
Shake    vigorously.     After    the    ether    has    separated 
and  has  risen  to  the  top,  decant.     Add  this  ethereal 


I29 

extract  to  a  few  cubic  centimeters  of  a  freshly  pre- 
pared tincture  of  gum  guaiac.  Finally  add  a  few 
drops  of  hydrogen  peroxide;  a  blue  color  indicates 
the  presence  of  blood.  Be  especially  careful  that  no 
blood  has  come  from  the  teeth,  or  from  abrasions  in 
the  mouth,  and  that  no  meat  is  in  the  fasting  contents 
you  are  testing.  Irritation  by  the  stomach  tube,  with 
the  consequent  production  of  small  hemorrhages,  is 
often  given  as  the  source  of  a  positive  guaiac  test. 
Practically  speaking,  the  writer  believes  that  it  is 
very  rare  for  the  stomach  tube  to  produce  enough 
irritation  to  cause  a  positive  guaiac  test,  and  most  of 
the  cases  which  he  has  seen  with  positive  tests, 
supposedly  due  to  trauma  from  the  tube,  have  after- 
wards turned  out  to  have  had  bleeding  ulcer  or 
cancer  of  the  stomach. 

II 

EXAMINATION  OF  THE  GASTRIC  CONTENTS   AFTER  A 
TEST  MEAL 

The  test  meal  ordinarily  used  in  Boston  is  that  of 
Ewald,  and  consists  of  a  medium-sized  slice  of  bread, 
and  a  glass  of  water.  It  is  given  on  an  empty  stomach, 
and  is  withdrawn  by  the  stomach  tube  at  the  end  of 
an  hour. 

Amount.  The  normal  amount  is  from  50  to  125  c.c. 
Larger  amounts  suggest  stasis,  hypersecretion  or 
hypomotility. 

Color.  The  normal  color  of  the  gastric  contents 
after  a  test  meal  is  the  white  color  of  the  bread  given. 
If  there  is  digested  blood  in  the  stomach,  the  color 
will  be  brown. 


CHEMICAL  EXAMINATION 

(a)  Blood.  It  is  wise  to  do  guaiac  tests  on  both 
the  fasting  and  the  test  meal  contents. 

(6)  Free  HC1.  The  free  HC1  and  the  total  acidity 
are  determined  quantitatively.  To  exactly  10  c.c.  of 
the  unfiltered  contents  add  a  drop  of  Topfer's  reagent. 
If  free  HC1  is  present  a  red  color  results.  Now  run 
in  -fo  sodic  hydrate  until  the  red  color  changes  to  yel- 
low. This  end  point  is  not  a  very  sharp  one,  and  care 
must  be  taken  not  to  over-titrate.  Multiply  the  num- 
ber of  cubic  centimeters  of  TO  sodic  hydrate  used  in 
this  titration  by  10.  This  gives  the  amount  of  free 
HC1  present  in  100  c.c.  of  gastric  contents  in  terms 
of  y\  sodic  hydrate.  The  per  cent  of  hydrochloric 
acid  may  be  obtained  if  the  above  quantity  is  multi- 
plied by  .00365.  The  normal  quantity  of  free  HC1 
is  equivalent  to  between  20  to  60  c.c.  T\  sodic  hydrate 
per  100  c.c.  gastric  contents,  or  from  .07  to..i8  per 
cent. 

Total  Acidity.  To  the  same  specimen  of  gastric 
contents  in  which  the  free  hydrochloric  acid  has  al- 
ready been  neutralized  with  sodic  hydrate,  add  a 
drop  or  two  of  a  I  per  cent  alcoholic  solution  of 
phenolphthalein.  Run  in  the  sodic  hydrate,  drop  by 
drop,  until  a  faint  pink  color  appears.  Multiply  the 
number  of  cubic  centimeters  of  y\  sodic  hydrate  used 
in  both  titrations  by  10;  this  gives  the  total  acidity 
of  100  c.c.  of  the  gastric  contents  in  terms  of  fV  sodic 
hydrate.  The  result  may  be  indicated  in  per  cent  of 
hydrochloric  acid  by  multiplying  this  result  by 
.00365.  The  normal  quantitative  values  for  total 
acidity  are  from  .15  to  .30  per  cent  or  40  to  80  c.c.  -fV 
sodic  hydrate  for  100  c.c.  gastric  contents. 


133 

Lactic  Acid.  Lactic  acid  is  rarely  present  when  free 
hydrochloric  acid  is.  Its  presence  indicates  the  lactic 
acid  fermentation  of  carbohydrate  food,  and  probably 
stasis.  It  may  be  tested  for  as  follows: 

Half  fill  two  test  tubes  with  a  very  dilute  ferric 
chloride  solution.  Add  a  few  drops  of  the  gastric 
contents  to  one  of  the  test  tubes,  and  compare  the 
color  with  that  of  the  control.  An  intensification 
of  the  yellow  color  indicates  that  lactic  acid  is 
present. 

Pepsin  and  Rennin.  Pepsin  is  always  present 
when  free  hydrochloric  acid  is.  If  free  hydrochloric 
acid  is  absent  it  may  be  tested  for  as  follows:  To  a 
small  portion  of  the  gastric  contents  add  enough 
hydrochloric  acid  to  make  it  give  the  test  for  free 
hydrochloric  acid,  then  add  a  small  open  tube  of 
coagulated  egg  albumin  to  the  contents,  and  leave  it 
in  a  warm  place  for  12  hours.  If  pepsin  is  present 
the  egg  albumin  will  show  signs  of  digestion. 

Rennin  also  is  always  present  when  free  hydro- 
chloric acid  is.  It  may  be  tested  for  by  neutralizing 
5  c.c.  of  gastric  contents,  adding  it  to  5  c.c.  of  milk, 
and  incubating  the  mixture.  If  a  normal  amount  is 
present,  the  milk  will  coagulate  within  15  minutes. 

Mercury.  In  testing  stomach  contents  or  feces  the 
same  method  is  employed  as  is  used  for  urine  (see  p. 
27),  although  the  quantity  of  material  taken  is 
usually  smaller.  The  material  must  be  well  mixed  to 
insure  getting  a  uniform  sample  of  the  specimen, 
especially  in  stomach  contents  if  egg  albumin  has  been 
given  as  an  antidote,  as  the  mercury  is  then  in  the 
form  of  albuminate.  The  oxidation  also  takes  longer, 
and  larger  quantities  of  potassium  chlorate  are  re- 


135 

quired.  Before  the  wire  is  placed  in  the  solution,  the 
latter  should  be  filtered  in  order  to  remove  any  fatty 
substances,  carbon  or  other  insoluble  materials. 
This  test  recognizes  mercury  in  a  I  to  100,000 
dilution. 


CHAPTER    V 
SPINAL    FLUIDS 

Pressure.  The  normal  spinal  fluid  is  under  very 
little  pressure.  Pathological  fluids  are  usually  under 
pressure,  the  amount  depending  upon  the  amount  of 
the  fluid. 

Appearance.  Normal  spinal  fluid  is  perfectly  clear ; 
pathological  may  be  opalescent  or  purulent. 

Blood  may  appear  in  the  fluid  in  cases  where  there 
has  been  a  fractured  skull  or  a  ruptured  blood  vessel 
from  other  cause;  or  it  may  be  due  to  trauma  of 
small  blood  vessels  caused  by  inserting  the  needle. 
Hemorrhage  during  lumbar  puncture  is  sometimes 
alarming,  but  it  almost  always  stops  soon  if  the  needle 
is  withdrawn  and  the  patient  kept  quiet. 

Fibrin  Clot.  In  normal  fluid*  no  fibrin  clot  forms 
on  standing;  in  pathological  fluids  a  fibrin  clot  is 
likely  to  form,  the  time  of  its  formation  depending 
upon  the  intensity  of  the  inflammation  and  the 
amount  of  fibrin  present. 

Amount.  The  normal  amount  obtained  by  lumbar 
puncture  may  vary  a  good  deal,  but  in  general  it  is 
not  over  20  c.c.  In  pathological  fluids  the  amount 
is  increased. 

In  certain  cases  of  meningitis,  however,  a  very 
small  amount,  or  no  fluid  at  all  may  be  obtained, 
owing  to  the  formation  of  adhesions,  which  prevent 
the  circulation  of  the  fluid. 

137 


139 
CHEMICAL  TESTS 

Pathological  spinal  fluid  usually  contains  an  excess 
of  globulin,  the  amount  depending  upon  the  activity 
of  the  inflammation  present.  This  may  be  tested  for 
as  follows: 

Globulin 

Noguchi's  Test.  To  one  part  of  spinal  fluid  add  four 
parts  of  10  per  cent  butyric  acid  in  normal  salt 
solution.  Boil,  and  then  add  as  much  normal  sodic 
hydrate  as  there  was  spinal  fluid  to  begin  with,  and 
boil  again.  Normal  fluids  may  give  a  faint  opal- 
escence,  pathological  ones  are  likely  to  give  a  flocculent 
precipitate,  indicating  an  excess  of  globulin. 

Nonne's  Test.  To  about  2  c.c.  of  spinal  fluid  in  a 
small  test  tube,  add  an  equal  amount  of  a  saturated 
solution  of  magnesium  sulphate,  and  compare  this 
tube  with  a  tube  containing  spinal  fluid  alone;  a 
white  precipitate  indicates  an  excess  of  globulin. 

Sugar.  Normal  spinal  fluid  contains  sugar,  and 
gives  a  prompt  reduction  of  Benedict's  reagent. 
Most  pathological  fluids  do  not.  In  general,  the  less 
reduction  there  is  obtained,  the  more  severe  is  the 
inflammation.  Sugar  may  be  tested  for  with  Bene- 
dict's or  Fehling's  reagent. 

MICROSCOPICAL  EXAMINATION 

i.  Cell  Count.  The  normal  cell  count  varies. 
Most  normal  fluids  contain  only  3  or  4  cells  per 
cubic  millimeter.  Authorities  differ  somewhat  as  to 
what  is  the  upper  limit  of  normality  in  the  cell  count. 
A  count  of  over  8  may  usually  safely  be  regarded  as 
abnormal. 


As  the  number  of  cells  in  a  spinal  fluid  may  vary 
from  I  to  10,000  or  more  per  cubic  millimeter,  the 
technique  of  counting  must  necessarily  be  varied 
somewhat  according  to  the  nature  of  the  fluid. 

(a)  Purulent  fluids  are  best  counted  with  exactly 
the  same  technique  used  for  the  white  blood  cells 
(see  p.  53). 

(b)  Clear  or  Slightly  Turbid  Fluids.     The  Zappert 
modification  of  the  Thoma-Zeiss  ruling  is  the  best  rul- 
ing for  the  counting  slide  for  clear  spinal  fluids.     In 
this  ruling,  besides  the  large  central  square,  which  is 
the  same  size  as  in  the  ordinary  Thoma-Zeiss  ruling, 
there  are  eight  other  large  squares  of  equal  size  around 
the  central  square.     (See  p.  52.) 

Technique  of  Count.  Rinse  the  white  blood  count- 
ing pipette  out  with  glacial  acetic  acid  (to  make  the 
cell  nuclei  stand  out),  and  draw  up  spinal  fluid  into  it, 
using  no  diluting  agent.  Put  a  drop  of  the  undiluted 
spinal  fluid  on  the  counting  stage  the  same  as  for  a 
blood  count,  and  count  5  of  the  large  squares.  Do 
the  same  with  a  second  drop. 

The  sum  of  the  two  counts  equals  the  number  of 
cells  per  cubic  millimeter. 

If  a  counting  chamber  with  the  modified  ruling  is 
not  available,  the  ordinary  Thoma-Zeiss  ruling  may 
be  used,  as  follows:  Count  all  the  cells  in  the  large 
central  square  in  5  different  drops  of  spinal  fluid,  and 
multiply  the  sum  of  the  counts  by  2. 

Differential  Count.  A  differential  count  of  the 
cells  may  be  made  at  the  same  time,  in  the  counting 
chamber,  as  the  acetic  acid  with  which  the  pipette 
has  been  rinsed  makes  the  nuclei  stand  out  very 
clearly.  Normally  all  the  cells  are  mononuclears. 


H3 

2.  Smear.  Smears  for  the  microscopic  study  of 
the  spinal  fluid  are  made  from  the  centrifuged  sedi- 
ment. It  is  rather  hard  to  prepare  these  satisfactorily, 
but  it  will  be  found  that  if  the  smear  is  allowed  to 
dry  of  itself,  without  heat,  the  best  preparations  will 
be  obtained.  The  best  staining  is  done  with  methyl- 
ene  blue.  In  the  stained  specimen  the  following  may 
be  seen : 

(a)  Lymphocytes  —  the    normal    cell    of    cerebro- 
spinal  fluid. 

(b)  Pus  cells  —  indicating  a  purulent  inflammation. 

(c)  Large  endothelial  cells  —  especially  likely  to 
be    seen   in   anterior    poliomyelitis   or  cerebrospinal 
syphilis. 

(d)  Bacteria. 

1 .  Meningococci.    These  organisms  appear  as  small, 
biscuit-shaped  diplococci  both  within  and  without  the 
leucocytes.     They  may  be  present  in  small  or  in  fairly 
large  numbers. 

2.  Pneumococci.     Small  or  large  cocci  growing  in 
pairs    or    in    short    chains,    sometimes    showing    the 
characteristic  surrounding  capsule.     When  pneumo- 
cocci  are  present  they  usually  appear  in  extraordi- 
narily large  numbers,  the  field  under  the  microscope 
often  resembling  a  smear  from  a  pure  culture  of  the 
pneumococcus. 

3.  Streptococci  and  staphylococci  may  be  easily 
recognized  by  their  characteristic  morphology. 

4.  Influenza  bacilli  appear  as  small,  thin,  rather 
faintly  staining  rods,  both  within  and  without  the 
leucocytes,  in  large  numbers. 

5.  Tubercle  bacilli  are  present  in  the  spinal  fluid 
in    all    cases    of    tubercular    meningitis.     There    are 


H5 

certain  experts  who  can  find  them  nearly  every  time, 
but  the  average  laboratory  worker  will  miss  them 
much  more  often  than  he  finds  them. 

The  two  best  methods  of  looking  for  them  are : 

1.  Make   a   smear   from  the  fibrin  clot  that   has 
formed  after  the  spinal  fluid  has  stood  for  some  time, 
and  stain  it  for  the  bacilli.     (See  p.  161.) 

2.  Centrifuge  the  spinal  fluid  at  a  high  speed  for 
one  hour,  and  make  a  thick  smear  from  the  sediment, 
letting  it  dry  of  itself  in  the  air. 

CHARACTERISTICS  OF  THE  SPINAL  FLUID  IN 
VARIOUS  DISEASES 

The  spinal  fluid  may  vary  considerably  in  different 
examples  of  the  same  disease,  or  at  different  periods 
during  the  course  of  the  disease.  The  data  given 
below  refer  to  the  average. 

1.  Tubercular  Meningitis.    Almost  always  slightly 
opalescent  —  rarely  clear  as  compared   with   water. 
Under  slight  or  considerably  increased  pressure.    May 
vary  in  amount  from  20  to  125  c.r.,  and  in  cell  count 
from   15  or  20  to   1000   cells   per   cubic   millimeter. 
The  cell  count  is  practically  never  below  10,  and  the 
most  common  count  that  one  sees  is  somewhere  in 
the  neighborhood  of   100.     Nearly  all  the  cells  are 
mononuclear.     The  globulin  test  may  be  positive  or 
negative,  more  often  positive.     A  fibrin  clot  usually 
forms.     Sugar  is  absent  in  about  25  per  cent  of  the 
cases. 

2.  Meningococcus     Meningitis.      Almost    always 
cloudy,  sometimes  very  thick.     The  amount  is  from 
5  to  125  c.c.,  and  it  may  be  under  slight  or  consid- 
erable pressure.     The  cell  count  is  high,  varying  from 


H7 

2OO  to  10,000  cells  per  cubic  millimeter.  The  cells 
are  mostly  polynuclear,  and  the  characteristic  biscuit- 
shaped  diplococci  may  be  seen  both  within  and  with- 
out the  leucocytes.  The  globulin  test  is  positive, 
and  a  fibrin  clot  forms  if  the  fluid  is  not  too  purulent. 
Fehling's  solution  is  usually'  not  reduced. 

3.  Pneumococcus,  streptococcus  and  staphylococcus 
meningitis  have  much  the  same  sort  of  fluid  that 
epidemic  meningitis  does,  except  that  the  etiologic 
organism  is  likely  to  be  present  in  greater  numbers 
than   is   the   diplococcus   intracellularis   in  epidemic 
meningitis. 

4.  Influenza   Meningitis.    A   cloudy  fluid,   under 
moderately    increased    pressure,    25    to    100    c.c.    in 
amount.     The  cell  count  varies;    in  three  cases  re- 
ported by  Brown  of  Toronto,  from   1600  to  3600. 
The  cells   are   nearly   all   polynuclears,   and   the   in- 
fluenza bacilli  are  seen  in  large  numbers  both  within 
and    without    the    leucocytes.     The    globulin    is    in- 
creased, and  the  sugar  decreased  or  absent. 

5.  Poliomyelitis.     Usually    under    moderately    in- 
creased pressure,  20  to  100  c.c.  in  amount.     Usually 
clear.     The  cell  count  is  moderately  increased,  from 
20  to  50  per  cubic  millimeter.     In  the  incubation  stage, 
most  of  the  cells  are  polynuclear,  later  on  in  the  course 
of  the  disease  they  are  mononuclear,  up  to  95  per 
cent.     Endothelial  cells  are  especially  likely  to  occur. 
There  is  usually  a  slightly  increased  globulin  content, 
and  there  may  or  may  not  be  a  fibrin  clot.     Sugar  is 
usually  present. 

6.  Encephalitis  is  now  thought  to  be    the    same 
disease  as  poliomyelitis,  but  is  confined  to  the  brain. 
The  fluid  is  the  same  as  that  of  poliomyelitis. 


149 

7.  Serous      Meningitis       (Meningismus).     Under 
slightly  increased  pressure.     The  amount  may  vary 
between  10  and  100  c.c.     The  fluid  is  usually  clear, 
has  a  normal  cell"  count,  and  reduces  Benedict's  solu- 
tion.    It  may  occasionally  have  a  slightly  increased 
globulin  content. 

8.  Hydrocephalus.     A  greatly  increased  amount, 
under    great    pressure.     Cell    count    and     globulin 
normal.     Reduces  Benedict's.     Wassermann  may  be 
positive. 

9.  Tabes  Dorsalis.     A  clear  fluid  under  slightly  in- 
creased pressure.     The  amount  may  vary  from  10  to 
30  c.c.     The  cell  count  may  vary  a  good  deal,  in 
certain  cases  being  almost  normal,  and  in  others  con- 
siderably increased.     The  usual  count  is  from  25  to 
75.     The  Wassermann  and  the  globulin  tests  may  be 
either  positive  or  negative,  but  are  more  likely  to  be 
negative.     Sugar  is  usually  present. 

10.  General   Paresis.     The   amount   and    macro- 
scopic character  of  the  fluid  is  about  the  same  as  it  is 
in  tabes.     The  cell  count  is  usually  a  little  lower, 
running  from  15  to  50. 

The  Wassermann  and  Globulin  tests  are  usually 
positive.  Sugar  is  present. 

11.  Cerebrospinal  Syphilis.     There  may  be  a  good 
deal  of  pressure  as  well  as  a  considerably  increased 
amount,  with  a  clear  or  slightly  opalescent  fluid,  de- 
pending   upon    the    acuteness    and    severity    of    the 
syphilitic  process. 

The  Wassermann  and  Globulin  tests  are  positive, 
the  cell  count  is  from  100  to  1500,  with  a  mono- 
nuclear  formula.  Sugar  may  or  may  not  be 
present. 


CHAPTER    VI 
PLEURAL   AND   PERITONEAL   FLUIDS 

A  transudate  is  an  accumulation  of  non-inflamma- 
tory fluid  in  one  of  the  body  cavities,  due  not  to  in- 
fection, but  usually  to  some  mechanical  disturbance  of 
circulation  or  to  impaired  kidney  function. 

An  exudate  is  an  inflammatory  fluid  due  to  irri- 
tation of  the  serous  lining  membrane  of  one  of  the 
body  cavities  by  some  microorganism. 

Transudates.  Transudates  are  usually  colorless, 
or  pale  straw-colored,  of  a  thin  consistency,  with  a 
specific  gravity  of  usually  under  1018,  and  an  albumin 
content  of  below  2  per  cent.  The  sediment  shows  a 
few  epithelial  and  endothelial  cells,  and  a  very  few 
leucocytes.  Transudates  very  rarely  clot. 

Exudates.  Exudates  may  vary  from  a  thin  con- 
sistency like  that  of  a  transudate,  to  a  thick,  creamy 
consistency,  due  to  the  presence  of  pus.  The  color 
varies  from  light  to  dark  straw  color.  The  specific 
gravity  is  usually  over  1018,  and  the  albumin  content 
over  2  per  cent.  Transudates  usually  clot  spon- 
taneously. 

The  sediment  contains  many  more  cells  than  does 
that  of  transudates,  the  cells  being  either  lympho- 
cytes or  polynuclear  cells  according  to  the  nature  of 
the  infection.  The  causative  microorganism  may 
sometimes  be  seen  in  the  stained  specimen,  often  in 
large  numbers. 


153 

It  is  often  of  importance  to  distinguish  between 
tubercular  and  other  fluids.  As  a  rule,  tubercular 
fluids  are  clear,  and  pale,  and  may  be  very  close  to  a 
transudate  in  some  of  their  properties.  There  may 
be  few  cells  in  the  sediment,  or  a  good  many,  and 
these  are  nearly  all  lymphocytes.  Any  pleural  or* 
peritoneal  exudate  which  shows  a  predominance  of 
lymphocytes  is  presumably  a  tubercular  fluid.  As 
it  is  not  at  all  easy  to  demonstrate  the  tubercle 
bacillus  in  tubercular  exudates,  it  is  best  to  inject  a 
few  cubic  centimeters  into  a  guinea  pig,  kill  the  pig 
after  six  weeks,  and  determine  whether  or  not  he  has 
developed  tuberculosis. 

EXAMINATION   OF   EXUDATES 

Albumin. — May  be  determined  by  the  Esbach 
tube,  as  used  for  urine  (see  p.  9).  As  exudates 
usually  have  a  much  higher  albumin  percentage  'than 
any  urine  that  is  ever  examined,  it  is  best  to  dilute 
I  to  10. 

Staining.  The  staining  is  best  done  immediately 
after  the  fluid  is  withdrawn.  If  it  is  desired  to  prevent 
clotting  a  few  cubic  centimeters  of  a  2  per  cent  solu- 
tion of  sodium  citrate  may  be  added.  The  fluid  is 
centrifuged  and  a  smear  made  from  the  sediment, 
drying  in  the  air  with  no  heat,  and  using  methyl 
alcohol  as  a  fixative  if  one  is  desired.  The  best  stain 
is  methylene  blue,  and  the  important  things  to  ob- 
serve in  the  stained  specimen  are  the  differential  count 
of  leucocytes  and  the  number  and  variety  of  any 
bacteria  which  may  be  present. 

Purulent  fluids  may  be  stained  with  Smith's  stain 
(see  p.  163). 


CHAPTER    VII 
SPUTUM 

Source.  The  sputum  may  be  composed  of  ma- 
terial from  the  mouth,  nose,  naso-pharynx,  trachea 
and  larynx,  bronchi  or  lungs.  Also,  material  from 
diseased  conditions  in  other  organs  may  find  its  way 
into  the  sputum.  Examples  of  this  are  amebic  liver 
abscesses  or  pyogenic  sub-diaphragmatic  abscesses 
perforating  into  the  lung,  or  pus  from  an  empyema 
perforating  into  a  large  bronchus. 

MACROSCOPIC   EXAMINATION 

Amount.  The  amount  varies  greatly.  Especially 
large  amounts  are  likely  to  be  seen  in  perforating 
empyema,  pulmonary  gangrene  or  abscess,  bronchiec- 
tasis,  and  certain  cases  of  bronchitis.  The  amount 
may  sometimes  reach  a  liter  or  more  in  the  twenty- 
four  hours. 

Consistency  and  Appearance.  May  be  very  thin 
or  very  thick  and  tenacious.  On  the  basis  of  the 
character  of  the  sputum  the  following  classification  is 
usually  made. 

1.  Frothy  —  seen  especially  in  acute  edema  of  the 
lungs. 

2.  Mucoid  —  especially  likely  to  be  seen  in  certain 
cases  of  bronchitis  and  in  edema  of  the  lungs  due  to 
chronic  cardiac  conditions. 

155 


157 

3.  Muco-purulent  —  common    in    many    diseases: 
pneumonia,  bronchitis,  tuberculosis,  etc. 

4.  Purulent  —  seen   in   any   inflammatory   or   de- 
structive process  within  the  respiratory  tract,  where 
there    is    pus    present    (tuberculosis,    bronchiectasis, 
bronchitis,     abscess,     perforating     empyema,     etc.). 
Purulent  sputum  may  be  homogeneous,  or  the  pus 
may  be  present  in  small  masses,  in  which  case  it  is 
said  to  be  nummular. 

5.  Bloody.     Blood  may  be  seen  in  the  sputum  in 
nearly  any  inflammatory  or  destructive  process  of  the 
respiratory  tract.     It  may  exist  as  bright  blood,  or 
dark  blood,  clotted  or  unclotted,  or  it  may  be  present 
as  changed  blood  pigment.     Blood  is  especially  likely 
to  be  found  in  the  sputum  in  pneumonia,  where  it 
is  very  intimately  mixed  with   the  thick    tenacious 
sputum,  giving  it  a  "  rusty  "  or  "  prune  juice  "  color, 
in    hemorrhagic    infarction    of    the  lung,  where  the 
blood  is  intimately  mixed  with  the  sputum,  but  does 
not  have  the  rusty  color  of  the  pneumonic  sputum,  or 
in  any  destructive  process  of  the  lung  in  which  ulcer- 
ation  has  occurred   (tuberculosis,  new  growth,  gan- 
grene).    Blood  is  also  likely  to  be  present  in  the  frothy 
sputum  of  acute  pulmonary  edema,  or  it  may  come 
from  ulcerative  processes  in  the  throat  or  esophagus. 

Odor.  Most  sputum  is  odorless  or  has  a  mildly 
offensive  odor.  In  abscess  or  gangrene  of  the  lung 
it  may  be  extremely  foul. 

Color.  Most  sputa  are  light  yellow,  from  mixed 
pus  and  mucus.  Purulent  sputa  are  a  darker  yellow, 
or  a  rather  light  greenish  yellow.  The  sputum  may 
be  green  in  jaundice,  or  in  chloroma  of  the  lung.  A 
rusty  red  or  "  prune  juice  "  color  is  characteristic  of 


159 

lobar  pneumonia.  The  sputum  of  amebic  liver 
abscess  rupturing  into  the  lung  has  the  characteristic 
brick  red  "  anchovy  sauce  "  color.  Gray  or  black 
sputum  is  usually  due  to  inhalation  of  carbon.  A 
chocolate  color  may  be  due  to  gangrene  of  the  lung. 

Casts  of  the  bronchi  may  be  seen  in  sputum  from 
fibrinous  bronchitis,  or  in  cases  of  diphtheria  where 
the  membrane  has  extended  down  into  the  bronchi. 

Lung  Tissue.  In  destructive  processes  of  the  lung, 
small  bits  of  lung  tissue  may  appear  in  the  sputum, 
as  dark  threads  or  small  masses. 

Dittrich's  plugs  are  small,  light-colored  particles 
occurring  occasionally  in  the  sputum,  usually  coming 
from  the  terminal  portions  of  the  small  bronchi,  or 
from  the  tonsillar  crypts.  They  are  composed  of 
fatty  acids,  epithelium  and  detritus,  and  have  a  very 
offensive  odor  when  crushed. 

"  Lung  stones  "  usually  are  small  masses  of  cal- 
cined tubercular  material,  and  may  occur  in  con- 
siderable numbers  in  the  sputum  from  certain  cases 
of  tuberculosis. 

Echinococcus  Cysts.  Portions  of  echinococcus 
cysts  are  sometimes  coughed  up  in  the  sputum  when 
there  is  echinococcus  disease  of  the  lung. 

Food  remains  of  various  sorts  may  be  present  in 
the  sputum,  and  should  not  be  confused  with  any  of 
the  pathological  constituents. 

MICROSCOPIC  EXAMINATION 

Bacteria 

Tubercle  Bacillus.  Select  a  thick  portion  of  the 
sputum,  and  make  a  smear  from  it  on  a  cover  glass, 
drying  gently  with  heat. 


1.  Cover  with  Ziehl's   carbol  fuchsin,   and   steam 
for  I  minute,  or  stain  without  heat  for  5  minutes. 

2.  Wash  in  water. 

3.  Decolorize  20  seconds  in  Czaplewski's  solution 
(3  per  cent  strong  HC1  in  95  per  cent  alcohol)  or  in 
20  per  cent  sulphuric  acid. 

4.  Wash  in  water. 

5.  Stain  with  Loeffler's  methylene  blue  30  seconds. 

6.  Wash  in  water,  dry,  and  mount  in  balsam.     The 
cells,  etc.,  of  the  sputum  stain  a  light  blue,  and  the 
tubercle  bacilli  a  bright  red.     They  show  an  especial 
tendency  to  occur  in  small  bundles. 

Antiformin  Method  of  Staining.  If  the  bacilli  are 
present  in  very  small  numbers  they  are  more  likely 
to  be  found  by  the  antiformin  method,  as  follows: 

To  10  or  20  c.c.  of  sputum  add  an  equal  volume  of 
antiformin  (antiformin  is  a  10  per  cent  solution  of 
sodium  hypochlorite,  containing  5  to  10  per  cent 
sodium  hydroxide),  and  mix  thoroughly,  until  the 
mixture  has  become  homogeneous.  All  but  the  acid- 
fast  group  of  organisms  are  destroyed.  Centrifuge, 
and  stain  the  sediment  for  tubercle  bacilli. 

OTHER   ORGANISMS 

The  sputum  contains  an  extremely  mixed  flora, 
and,  as  many  organisms  which  may  be  pathogenic  are 
normally  present  in  it,  it  is  unwise  to  draw  too  hasty 
conclusions  as  to  the  etiology  of  a  disease  from  the 
bacteriology  of  the  sputum.  In  general,  if  one 
organism  is  present  in  very  large  numbers,  to  the  ex- 
clusion of  the  other  organisms,  it  is  likely  to  be  the 
etiologic  factor  of  the  disease.  Thus,  one  would  pay 
but  little  attention  to  a  few  influenza  bacilli  in  the 


CAST  OF  A  BRONCHUS. 


PNEUMOCOCCI. 


163 

sputum,  but  if  they  were  present  in  large  numbers,  in 
nearly  pure  culture,  as  they  sometimes  are,  one  would 
expect  that  they  were  important  in  the  etiology  of  the 
disease. 

A  very  satisfactory  stain  for  all  the  bacteria  in 
the  sputum  except  the  tubercle  bacillus,  is  that  of 
W.  H.  Smith.  In  the  routine  examination  of  a 
specimen  of  sputum,  two  preparations  should  always 
be  made;  one  stained  for  the  tubercle  bacillus,  and 
one  stained  with  Smith's  stain,  as  follows: 

1.  Make  a  thin  cover  glass  smear  of  the  sputum. 

2.  Stain  with  aniline  oil  gentian  violet  long  enough 
to  run  through  the  flame  once  or  twice,  steaming 
gently. 

3.  Stain   with    Gram's   iodine   solution,    steaming 
gently  for  a  moment,  as  before. 

4.  Wash  with  95  per  cent  alcohol  until  no  more 
color  comes  out. 

5.  Wash  in  water. 

6.  Stain  with  a  I  per  cent  aqueous  eosin  solution 
for  15  seconds,  steaming  gently." 

7.  Wash  in  water. 

8.  Stain  with  Loeffler's  methylene  blue  for  about 
30  seconds. 

9.  Wash  in  absolute   alcohol,  followed   by  xylol, 
and  mount  in  balsam. 

;  With  this  stain  the  Gram-positive  organisms  ap- 
pear dark  purple,  the  Gram-negative  light  blue,  and 
the  protoplasm  of  the  cells  pink.  Capsules  stain  pink, 
and  eosinophile  cells  are  easily  recognized. 

Pneumococcus  occurs  as  a  small,  Gram-positive 
encapsulated  diplococcus,  but  may  grow  in  chains, 
which  (if  the  capsule  does  not  show  up  well)  are  some- 


STREPTOCOCCUS  Mucosus  CAPSULATUS. 
(Pseudopneumococcus.) 


•-~:>T*K  '-Ty 
ZffiifiUm 

•;<  ,'-»ti    '  .*     ;'. 


INFLUENZA  BACILLI. 


165 

times  difficult  to  distinguish  from  streptococcus 
chains.  The  various  groups  of  pneumococci  must  be 
differentiated  by  their  agglutination  reactions. 
Pneumococci  are  present  in  nearly  every  sputum  in 
small  numbers,  and  cannot  be  regarded  as  the  etiologic 
organism  of  the  disease  unless  they  are  numerous. 

Streptococcus  is  a  small  Gram-positive  organism 
occurring  in  chains,  long  or  short.  It  is  seen  in  many 
sputa  as  a  secondary  infection,  but  is  sometimes  the 
etiologic  organism  of  bronchitis  or  pneumonia. 

Streptococcus  mucosus  capsulatus  (pseudopneumo- 
coccus)  is  a  very  large,  Gram-positive  encapsulated 
diplococcus,  appearing  usually  in  large  chains.  It 
may  be  recognized  by  its  large  size  and  distinct 
capsule.  It  is  a  very  virulent  organism,  and  if  it  is 
the  etiologic  organism  in  a  case  of  pneumonia,  the 
prognosis  is  bad.  It  is  said  by  some  to  be  present 
normally  in  small  numbers  around  the  teeth. 

Staphylococcus  is  a  small,  Gram-positive  coccus, 
appearing  in  bunches.  It  occurs  to  a  greater  or  lesser 
extent  in  nearly  every  sputum,  and  is  sometimes  seen 
in  large  numbers  as  a  secondary  infective  agent  in 
the  sputum  from  cases  of  tuberculosis,  lung  abscess, 
bronchiectasis,  etc. 

Influenza  Bacillus.  This  organism  is  of  consider- 
able importance  as  an  etiologic  agent  in  various 
respiratory  infections,  especially  in  chronic  bron- 
chiectasis and  sometimes  in  acute  bronchitis  or 
bronchopneumonia.  It  is  a  very  small,  short  bacillus, 
and  when  it  is  the  cause  of  a  disease  it  usually  ap- 
pears in  very  large  numbers  in  the  sputum,  both  within 
and  without  the  leucocytes.  It  does  not  grow  on 
ordinary  media,  but  must  be  grown  on  blood  agar. 


i67 

This  is  prepared  by  smearing  a  drop  of  blood  from  the 
finger  (taken  under  sterile  precautions)  over  the  sur- 
face of  the  agar  in  an  ordinary  culture  tube.  A  loop- 
ful  of  the  sputum  is  planted  on  this.  The  influenza 
colonies  appear  as  very  small,  clear,  "  dew  drop  "  like 
dots,  which  can  best  be  seen  with  a  hand  lens.  It  is 
Gram-negative. 

Pneumobacillus  (Friedlander)  occurs  as  plump  rods 
with  rounded  ends,  varying  in  size  and  shape,  and 
often  much  resembling  diplococci.  It  is  Gram-nega- 
tive, often  occurs  in  pairs,  and  may  have  a  capsule. 

If  this  bacillus  is  found  in  large  numbers  in  the 
sputum  of  a  case  of  pneumonia,  the  patient  is  very 
likely  to  die,  as  the  mortality  is  always  very  high  in 
pneumonia  of  this  type. 

Micrococcus  tetragenus  is  a  small  coccus  in  tetrad 
form,  within  a  capsule,  which  is  likely  to  appear  in 
mixed  infections.  It  is  Gram-positive.  It  is  not  of 
much  practical  importance. 

Micrococcus  catarrhalis  is  a  diplococcus  or  some- 
times a  tetracoccus,  but  does  not  form  chains.  It 
looks  very  much  like  a  gonococcus,  but  is  larger.  It 
is  Gram-negative.  At  one  time  this  organism  was 
thought  to  be  of  a  good  deal  of  importance  in  causing 
various  respiratory  infections,  especially  in  children, 
but  is  not  now  considered  very  important.  It  may 
occur  normally  in  the  sputum. 

MOLDS,  YEASTS  AND  FUNGI 

Actinomycosis  of  the  lung  is  a  rare  condition. 
Macroscopically  the  actinomyces  occur  as  small 
"  sulphur  granule  "  particles  in  the  sputum.  When 
one  of  these  is  crushed  on  a  glass  slide,  and  examined 


169 

under  the  microscope,  it  is  seen  to  consist  of  numerous 
rather  fine  threads,  which  radiate  from  a  center  in  a 
fan-like  manner.  The  extremities  of  these  threads 
may  be  club-shaped. 

Yeasts  may  be  present  in  the  sputum.  They  may 
closely  resemble  fat  droplets,  but  may  be  distinguished 
by  their  property  of  budding.  They  are  usually  not 
pathogenic. 

Blastomycetes  belong  to  the  same  general  plant 
group  as  yeasts.  They  may  cause  blastomycosis  of 
the  lung,  a  very  rare  condition. 

They  are  oval  or  round  in  shape,  and  have  a  granular 
protoplasm  with  a  double  capsule.  This  is  separated 
from  the  protoplasm  by  a  clear  zone.  Reproduction 
in  the  lung  tissue  is  by  budding.  They  are  usually 
found  in  the  sputum  in  large  numbers  when  the 
disease  is  present. 

Molds.  Are  not  commonly  seen  in  the  sputum, 
but  occur  occasionally,  as  the  air  is  full  of  them. 
There  are  over  a  hundred  varieties.  They  occur 
usually  as  a  secondary  infection  in  tubercular  or  other 
destructive  processes,  and  are  characterized  especially 
by  their  spores,  which  are  likely  to  be  black,  and  by 
their  filamentous  mycelia. 

OTHER  BODIES  OCCURRING  IN  THE  SPUTUM 
Epithelial  Cells.  As  the  entire  respiratory  tract, 
from  mouth  and  nose  to  lung  alveoli,  is  lined  with 
epithelium,  epithelial  cells  of  various  sorts  may  be 
found  in  the  sputum.  They  have  little  practical 
importance. 

Elastic  Tissue.  Elastic  tissue  may  be  found  in 
the  sputum.  When  found  it  is  an  absolute  indication 


that  a  destructive  process  of  the  lung  is  going  on. 
It  must  not  be  confused  with  threads  of  cotton  or 
silk,  mycelia  of  various  molds,  or  elongated  fatty  acid 
crystals.  True  elastic  fibers  are  waxy,  extremely 


Elastic  Fibers. 


Elastic  Fibers  in  alveolar  arrangement. 


refractive,  usually  rather  clean-cut  in  outline,  with 
rounded  ends.  They  may  sometimes  occur  in  alveolar 
arrangement.  The  best  way  to  look  for  elastic  tissue 
is  to  boil  the  sputum  with  an  equal  volume  of  10  per 
cent  sodic  hydrate  until  the  mixture  is  homogeneous, 
dilute  with  four  times  its  volume  of  water,  centrifuge, 
and  examine  the  sediment  with  the  low  power  of  the 
microscope. 

Charcot-Leyden  crystals,  eosinophiles,  and  Cursch- 
mann's  spirals  may  be  considered  together,  as  they 
usually  occur  together  in  cases  of  bronchial  asthma, 


CURSCHMANN'S  SPIRAL. 


CHARCOT-LEYDEN  CRYSTALS. 


173 

although  they  may  occasionally  be  seen  in  the  sputum 
from  other  diseases. 

Charcot-Leyden  crystals  are  seen  in  nearly  every 
case  of  bronchial  asthma.  They  are  rather  long  and 
slender,  straight,  hexagonal  double  pyramids,  are 
colorless,  and  may  vary  a  good  deal  in  size.  They 
are  probably  derived  from  disintegrated  matter  of  the 
eosinophile  cells. 

Eosinophile  cells  in  the  sputum  are  especially 
characteristic  of  bronchial  asthma.  They  are  usually 
mononuclear,  not  very  clean-cut  in  appearance,  and 
resemble  the  eosinophilic  myelocytes  of  the  blood. 

Curschmann's  spirals  appear  as  fine  collections  of 
threads  twisted  spirally,  usually  containing  eosino- 
philes  and  Charcot-Leyden  crystals  in  the  meshes  of 
threads.  They  are  nearly  visible  to  the  naked  eye, 
and  hence  should  be  looked  for  with  the  low  power 
of  the  microscope.  They  usually  stand  out  quite 
sharply  against  the  structureless  background  of  the 
sputum. 

Hematoidin  crystals  may  occur  in  the  sputum 
either  in  needles  or  rhombic  form.  They  are  es- 
pecially likely  to  be  seen  in  sputum  coming  from 
closed  cavities  containing  old  pus  mixed  with  blood, 
such  as  occur  in  empyema,  lung  abscess,  amebic  liver 
abscess,  etc. 

Their  color  is  a  bright  brownish  yellow. 

Cholesterin  crystals  may  be  seen  under  the  same 
conditions. 


CHAPTER  VIII 
MISCELLANEOUS 

Gram's  Stain  for  Gonococcus. 

1.  Make  a  thin  smear  of  the  suspected  pus  on  a 
cover  glass. 

2.  Stain  i  minute  with  aniline  oil  gentian  violet. 

3.  Wash  in  water. 

4.  Stain  2  minutes  with   Gram's   iodine  solution 
(IKI). 

5.  Wash  in  water. 

6.  Decolorize  in  95  per  cent  alcohol  until  no  more 
color  comes  out. 

7.  Wash  in  water. 

8.  Counterstain  I  minute  with  Bismarck  brown. 

9.  Dry  and  mount. 

The  gonococci  appear  as  rather  large,  biscuit- 
shaped  diplococci,  both  within  and  without  the  pus 
cells. 

Spirochaeta  Pallida  (in  primary  lesions).  Best 
stained  for  with  Wright's  blood  stain  in  the  same 
manner  as  staining  a  blood  film. 

Schick  Test.  The  value  of  this  test  is  that  it 
shows  whether  or  not  a  person  possesses  a  natural 
immunity  to  diphtheria.  One-fiftieth  of  the  mini- 
mal lethal  dose  (guinea  pig)  of  diphtheria  toxin, 
diluted  to  .1  c.c.  with  salt  solution,  is  injected 
intmcutaneously. 

The  reaction  appears  in  from  24  to  48  hours  after 
i75 


177 

the  injection,  and  consists  of  an  area  of  erythema, 
with  a  brownish  tinge,  measuring  .5  to  2  cm.  It 
usually  reaches  its  height  in  48  to  72  hours,  and  then 
fades. 

If  the  reaction  does  not  occur  it  shows  that  the 
patient  probably  possesses  sufficient  natural  immunity 
to  diphtheria  to  ward  off  the  infection  if  exposure 
should  occur. 

Von  Pirquet  (skin)  Tuberculin  Test.  With  a  small 
awl-like  implement  the  skin  of  the  forearm  is  scarified 
in  three  small  places  about  two  centimeters  apart. 
Especial  care  should  be  taken  not  to  scarify  deeply 
enough  to  draw  the  blood.  A  drop  of  old  tuberculin 
is  applied  to  the  outside  scarifications,  the  inner  one 
being  left  as  a  control,  and  is  allowed  to  dry  a  moment, 
and  a  light  gauze  dressing  is  applied. 

The  reaction,  if  -positive,  usually  appears  within 
24  hours,  but  should  not  be  called  negative  until  48 
hours  have  elapsed. 

The  reaction  consists  of  small,  raised,  reddened  and 
indurated  areas  about  the  points  where  the  tuberculin 
has  been  applied. 

GRAM-POSITIVE  AND  GRAM-NEGATIVE  ORGANISMS 

(Mallory  and  Wright) 
Gram  +  Gram  — 

Staphylococcus  pyogenes      Gonococcus. 

aureus.  Diplococcus    intracellularis 

Staphylococcus  pyogenes          meningiditis. 

albus.  Typhoid  bacillus. 

Streptococcus  pyogenes.  Bacillus  coli  communis. 

Streptococcus  capsulatus.  Spirillum  of  Asiatic  cholera. 

Pneumococcus.  Bacillus  pyocyaneus. 

Micrococcus  tetragenus.  Bacillus  of  influenza. 

Bacillus  diphtherise.  Bacillus  of  glanders. 


179 


Gram  + 

Bacillus  tuberculosis. 
Bacillus  of  anthrax. 
Bacillus  of  tetanus. 
Bacillus  aerogenes  capsulatus. 
Bacillus  of  malignant  edema. 


Gram  — 

Bacillus  proteus. 
Bacillus  mucosus  capsulatus. 
Bacillus  of  dysentery. 
Bacillus  of  bubonic  plague. 
Bacillus  of  chancroid. 


DISEASES  IN  WHICH 

THERE  IS  A  LEUCOCY- 

TOSIS. 

Actinomycosis. 
Amebiasis  (not  always). 
Appendicitis. 
Bronchitis. 
Bubonic  plague. 
Diphtheria. 
Endocarditis  (acute). 
Erysipelas. 

Gonorrhea  (complicated). 
Hydatid  disease. 
Meningitis  (cerebrospinal). 
Meningitis  (tubercular). 
Mumps  (lymphocytosis). 
Osteomyelitis. 
Pancreatitis  (acute). 
Pneumonia. 
Purpura. 
Pyelitis. 

Rheumatism  (acute  articular). 
Rickets  (in  severe  cases). 
Scarlet  fever. 
Scurvy. 
Tonsillitis. 
Typhus  fever. 

Whooping    cough    (lymphocy- 
tosis). 


DISEASES  IN  WHICH 

THERE  IS  NO  LEUCOCY- 

TOSIS. 

Influenza. 

Malaria  (usually  leukopenia). 
Measles  (usually  leukopenia). 
Pernicious    anemia    (leukope- 
nia). 
Syphilis. 
Tuberculosis. 

Typhoid  fever  (leukopenia). 
Variola. 


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